Does recall bias explain the association of mood disorders with workplace harassment?

Purpose: To determine the contribution of recall bias to the observed excess in mental ill-health in those reporting harassment at work. Methods: A prospective cohort of 1885 workers in welding and electrical trades was contacted every six months for up to 5 years, asking whether they were currently anxious or depressed and whether this was made worse by work. Only at the end of the study did we ask about any workplace harassment they had experienced at work. We elicited sensitivity and specificity of self-reported bullying from published reliability studies and formulated priors that reflect the possibility of over-reporting of workplace harassment (exposure) by those whose anxiety or depression was reported to be made worse by work (cases). We applied the resulting misclassification models to probabilistic bias analysis (PBA) of relative risks. Results: We observe that PBA implies that it is unlikely that biased misclassification due to the study subjects' states of mind could have caused the entire observed association. Indeed, the results demonstrated that doubling of risk of anxiety or depression following workplace harassment is plausible, with the unadjusted relative risk attenuated with understated uncertainty. Conclusions: It seems unlikely that risk of anxiety or depression following workplace harassment can be explained by the form of recall bias that we proposed.

Work Characteristics, Workplace Support, and Mental Ill-Health in a Canadian Cohort of Healthcare Workers During the COVID-19 Pandemic.

OBJECTIVE: The aim of the study was to identify determinants of mental health in healthcare workers (HCW) during the COVID-19 pandemic. METHODS: A cohort of Canadian HCW completed four questionnaires giving details of work with patients, ratings of workplace supports, a mental health questionnaire, and substance use. Principal components were extracted from 23 rating scales. Risk factors were examined by Poisson regression. RESULTS: A total of 4854 (97.8%) of 4964 participants completed ratings and mental health questionnaires. Healthcare workers working with patients with COVID-19 had high anxiety and depression scores. One of three extracted components, 'poor support,' was related to work with infected patients and to anxiety, depression, and substance use. Availability of online support was associated with feelings of better support and less mental ill-health. CONCLUSIONS: Work with infected patients and perceived poor workplace support were related to anxiety and depression during the pandemic.

Excess risk of COVID-19 infection and mental distress in healthcare workers during successive pandemic waves: Analysis of matched cohorts of healthcare workers and community referents in Alberta, Canada.

OBJECTIVES: To investigate changes in risk of infection and mental distress in healthcare workers (HCWs) relative to the community as the COVID-19 pandemic progressed. METHODS: HCWs in Alberta, Canada, recruited to an interprovincial cohort, were asked consent to link to Alberta's administrative health database (AHDB) and to information on COVID-19 immunization and polymerase chain reaction (PCR) testing. Those consenting were matched to records of up to five community referents (CRs). Physician diagnoses of COVID-19 were identified in the AHDB from the start of the pandemic to 31 March 2022. Physician consultations for mental health (MH) conditions (anxiety, stress/adjustment reaction, depressive) were identified from 1 April 2017 to 31 March 2022. Risks for HCW relative to CR were estimated by fitting wave-specific hazard ratios. RESULTS: Eighty percent (3050/3812) of HCWs consented to be linked to the AHDB; 97% (2959/3050) were matched to 14,546 CRs. HCWs were at greater risk of COVID-19 overall, with first infection defined from either PCR tests (OR=1.96, 95%CI 1.76-2.17) or physician records (OR=1.33, 95%CI 1.21-1.45). They were also at increased risk for each of the three MH diagnoses. In analyses adjusted for confounding, risk of COVID-19 infection was higher than for CRs early in the pandemic and during the fifth (Omicron) wave. The excess risk of stress/adjustment reactions (OR=1.52, 95%CI 1.35-1.71) and depressive conditions (OR=1.39, 95%CI 1.24-1.55) increased with successive waves during the epidemic, peaking in the fourth wave. CONCLUSION: HCWs were at increased risk of both COVID-19 and mental ill-health with the excess risk continuing late in the pandemic.

RéSUMé: OBJECTIFS: Étudier l'évolution du risque d'infection et de problèmes de santé mentale (PSM) chez les travailleurs de la santé (TdS), comparé à la population générale, au cours de la pandémie de COVID-19. MéTHODES: Certains TdS de l'Alberta (Canada) participant à une cohorte interprovinciale, ont consenti à ce que la base administrative de santé de l'Alberta (AHDB) nous transmette leurs données de vaccination contre la COVID-19 et de tests d'amplification des acides nucléiques (TAAN). Ceux ayant consenti ont été appariés à un maximum de cinq témoins de population générale. Les diagnostics médicaux (par médecins) de COVID-19 ont été identifiés dans l'AHDB du début de la pandémie jusqu'au 31 mars 2022. Les consultations médicales pour PSM (anxiété, stress/troubles de l'adaptation, dépression) ont été identifiées entre le 1er avril 2017 et le 31 mars 2022. Les rapports de cotes (RC) comparant les TdS aux témoins de la population générale ont été estimés pour chaque vague d'infection. RéSULTATS: Quatre-vingts pourcent (80 %; 3050/3812) des TdS ont donné leur consentement à ce que leurs données nous soient transmises par l'AHDB; 97 % d'entre eux (2959/3050) ont été appariés à 14 546 témoins. Dans l'ensemble, les TdS étaient plus à risque de COVID-19, avec une première infection identifiée soit par les TANN (RC=1,96, IC de 95% 1,76-2,17), soit via les dossiers médicaux (RC=1,33, IC de 95% 1,21-1,45). Ils étaient également plus à risque pour chacun des trois problèmes de SM. Le risque de COVID-19 ajustés pour les facteurs de confusion était plus élevé que chez les témoins au début de la pandémie et durant la cinquième vague (variant Omicron). Les excès de risque de stress/troubles de l'adaptation (RC=1,52, IC de 95% 1,35-1,71) et de dépression (RC=1,39, IC de 95% 1,24-1,55) ont augmenté au fil des vagues de l'épidémie, avec un pic à la quatrième vague. CONCLUSION: Les TdS étaient plus à risque d'infection de COVID-19 et de troubles de santé mentale avec cet excès de risque se prolongeant plus tard dans la pandémie.

Reported harassment and mental ill-health in a Canadian prospective cohort of women and men in welding and electrical trades.

OBJECTIVES: Experience of psychosocial environments by workers entering trade apprenticeships may differ by gender. We aimed to document perceived harassment and to investigate whether this related to mental ill-health. METHODS: Cohorts of workers in welding and electrical trades were established, women recruited across Canada and men from Alberta. Participants were recontacted every 6 months for up to 3 years (men) or 5 years (women). At each contact, they were asked about symptoms of anxiety and depression made worse by work. After their last regular contact, participants received a "wrap-up" questionnaire that included questions on workplace harassment. In Alberta, respondents who consented were linked to the administrative health database that recorded diagnostic codes for each physician contact. RESULTS: One thousand eight hundred and eighty five workers were recruited, 1,001 in welding trades (447 women), and 884 in electrical trades (438 women). One thousand four hundred and nineteen (75.3%) completed a "wrap up" questionnaire, with 1,413 answering questions on harassment. Sixty percent of women and 32% of men reported that they had been harassed. Those who reported harassment had more frequently recorded episodes of anxiety and depression made worse by work in prospective data. In Alberta, 1,242 were successfully matched to administrative health records. Those who reported harassment were more likely to have a physician record of depression since starting their trade. CONCLUSIONS: Tradeswomen were much more likely than tradesmen to recall incidents of harassment. The results from record linkage, and from prospectively collected reports of anxiety and depression made worse by work, support a conclusion that harassment resulted in poorer mental health.

Patellofemoral joint geometry and osteoarthritis features 3-10 years after knee injury compared with uninjured knees.

In this cross-sectional study, we compared patellofemoral geometry in individuals with a youth-sport-related intra-articular knee injury to uninjured individuals, and the association between patellofemoral geometry and magnetic resonance imaging (MRI)-defined osteoarthritis (OA) features. In the Youth Prevention of Early OA (PrE-OA) cohort, we assessed 10 patellofemoral geometry measures in individuals 3-10 years following injury compared with uninjured individuals of similar age, sex, and sport, using mixed effects linear regression. We also dichotomized geometry to identify extreme (>1.96 standard deviations) features and assessed likelihood of having extreme values using Poisson regression. Finally, we evaluated the associations between patellofemoral geometry with MRI-defined OA features using restricted cubic spline regression. Mean patellofemoral geometry did not differ substantially between groups. However, compared with uninjured individuals, injured individuals were more likely to have extremely large sulcus angle (prevalence ratio [PR] 3.9 [95% confidence interval, CI: 2.3, 6.6]), and shallow lateral trochlear inclination (PR 4.3 (1.1, 17.9)) and trochlear depth (PR 5.3 (1.6, 17.4)). In both groups, high bisect offset (PR 1.7 [1.3, 2.1]) and sulcus angle (PR 4.0 [2.3, 7.0]) were associated with cartilage lesion, and most geometry measures were associated with at least one structural feature, especially cartilage lesions and osteophytes. We observed no interaction between geometry and injury. Certain patellofemoral geometry features are correlated with higher prevalence of structural lesions compared with injury alone, 3-10 years following knee injury. Hypotheses generated in this study, once further evaluated, could contribute to identifying higher-risk individuals who may benefit from targeted treatment aimed at preventing posttraumatic OA.

Cohort profile: recruitment and retention in a prospective cohort of Canadian healthcare workers during the COVID-19 pandemic.

PURPOSE: Healthcare workers were recruited early in 2020 to chart effects on their health as the COVID-19 pandemic evolved. The aim was to identify modifiable workplace risk factors for infection and mental ill health. PARTICIPANTS: Participants were recruited from four Canadian provinces, physicians (medical doctors, MDs) in Alberta, British Columbia, Ontario and Quebec, registered nurses (RNs), licensed practical nurses (LPNs) and healthcare aides (HCAs) in Alberta and personal support workers (PSWs) in Ontario. Volunteers gave blood for serology testing before and after vaccination. Cases with COVID-19 were matched with up to four referents in a nested case-referent study. FINDINGS TO DATE: Overall, 4964/5130 (97%) of those recruited joined the longitudinal cohort: 1442 MDs, 3136 RNs, 71 LPNs, 235 PSWs, 80 HCAs. Overall, 3812 (77%) were from Alberta. Prepandemic risk factors for mental ill health and respiratory illness differed markedly by occupation. Participants completed questionnaires at recruitment, fall 2020, spring 2021, spring 2022. By 2022, 4837 remained in the cohort (127 had retired, moved away or died), for a response rate of 89% (4299/4837). 4567/4964 (92%) received at least one vaccine shot: 2752/4567 (60%) gave postvaccine blood samples. Ease of accessing blood collection sites was a strong determinant of participation. Among 533 cases and 1697 referents recruited to the nested case-referent study, risk of infection at work decreased with widespread vaccination. FUTURE PLANS: Serology results (concentration of IgG) together with demographic data will be entered into the publicly accessible database compiled by the Canadian Immunology Task Force. Linkage with provincial administrative health databases will permit case validation, investigation of longer-term sequelae of infection and comparison with community controls. Analysis of the existing dataset will concentrate on effects on IgG of medical condition, medications and stage of pregnancy, and the role of occupational exposures and supports on mental health during the pandemic.

Use of Biostatistical Models to Manage Replicate Error in Concussion Biomarker Research.

Importance: Advancing research on fluid biomarkers associated with sport-related concussion (SRC) highlights the importance of detecting low concentrations using ultrasensitive platforms. However, common statistical practices may overlook replicate errors and specimen exclusion, emphasizing the need to explore robust modeling approaches that consider all available replicate data for comprehensive understanding of sample variation and statistical inferences. Objective: To evaluate the impact of replicate error and different biostatistical modeling approaches on SRC biomarker interpretation. Design, Setting, and Participants: This cross-sectional study within the Surveillance in High Schools to Reduce the Risk of Concussions and Their Consequences study used data from healthy youth athletes (ages 11-18 years) collected from 3 sites across Canada between September 2019 and November 2021. Data were analyzed from November 2022 to February 2023. Exposures: Demographic variables included age, sex, and self-reported history of previous concussion. Main Outcomes and Measures: Outcomes of interest were preinjury plasma glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neurofilament-light (NFL), total tau (t-tau) and phosphorylated-tau-181 (p-tau-181) assayed in duplicate. Bland-Altman analysis determined the 95% limits of agreement (LOAs) for each biomarker. The impact of replicate error was explored using 3 biostatistical modeling approaches assessing the associations of age, sex, and previous concussion on biomarker concentrations: multilevel regression using all available replicate data, single-level regression using the means of replicate data, and single-level regression with replicate means, excluding specimens demonstrating more than 20% coefficient variation (CV). Results: The sample included 149 healthy youth athletes (78 [52%] male; mean [SD] age, 15.74 [1.41] years; 51 participants [34%] reporting ≥1 previous concussions). Wide 95% LOAs were observed for GFAP (-17.74 to 18.20 pg/mL), UCH-L1 (-13.80 to 14.77 pg/mL), and t-tau (65.27% to 150.03%). GFAP and UCH-L1 were significantly associated with sex in multilevel regression (GFAP: effect size, 15.65%; ß = -0.17; 95% CI, -0.30 to -0.04]; P = .02; UCH-L1: effect size, 17.24%; ß = -0.19; 95% CI, -0.36 to -0.02]; P = .03) and single-level regression using the means of replicate data (GFAP: effect size, 15.56%; ß = -0.17; 95% CI, -0.30 to -0.03]; P = .02; UCH-L1: effect size, 18.02%; ß = -0.20; 95% CI, -0.37 to -0.03]; P = .02); however, there was no association for UCH-L1 after excluding specimens demonstrating more than 20% CV. Excluding specimens demonstrating more than 20% CV resulted in decreased differences associated with sex in GFAP (effect size, 12.29%; ß = -0.14; 95% CI, -0.273 to -0.004]; P = .04) and increased sex differences in UCH-L1 (effect size, 23.59%; ß = -0.27; 95% CI, -0.55 to 0.01]; P = .06), with the widest 95% CIs (ie, least precision) found in UCH-L1. Conclusions and Relevance: In this cross-sectional study of healthy youth athletes, varying levels of agreement between SRC biomarker technical replicates suggested that means of measurements may not optimize precision for population values. Multilevel regression modeling demonstrated how incorporating all available biomarker data could capture replicate variation, avoiding challenges associated with means and percentage of CV exclusion thresholds to produce more representative estimates of association.

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.

Factors Associated With Concussion Rates in Youth Ice Hockey Players: Data From the Largest Longitudinal Cohort Study in Canadian Youth Ice Hockey.

OBJECTIVES: To examine factors associated with rates of game and practice-related concussion in youth ice hockey. DESIGN: Five-year prospective cohort (Safe2Play). SETTING: Community arenas (2013-2018). PARTICIPANTS: Four thousand eighteen male and 405 female ice hockey players (6584 player-seasons) participating in Under-13 (ages 11-12), Under-15 (ages 13-14), and Under-18 (ages 15-17) age groups. ASSESSMENT OF RISK FACTORS: Bodychecking policy, age group, year of play, level of play, previous injury in the previous year, lifetime concussion history, sex, player weight, and playing position. MAIN OUTCOME MEASUREMENTS: All game-related concussions were identified using validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician for diagnosis and management. Multilevel Poisson regression analysis including multiple imputation of missing covariates estimated incidence rate ratios (IRRs). MAIN RESULTS: A total of 554 game and 63 practice-related concussions were sustained over the 5 years. Female players (IRR Female/Male = 1.79; 95% CI: 1.26-2.53), playing in lower levels of play (IRR = 1.40; 95% CI: 1.10-1.77), and those with a previous injury (IRR = 1.46; 95% CI: 1.13, 1.88) or lifetime concussion history (IRR = 1.64; 95% CI: 1.34-2.00) had higher rates of game-related concussion. Policy disallowing bodychecking in games (IRR = 0.54; 95% CI: 0.40-0.72) and being a goaltender (IRR Goaltenders/Forwards = 0.57; 95% CI: 0.38-0.87) were protective against game-related concussion. Female sex was also associated with a higher practice-related concussion rate (IRR Female/Male = 2.63; 95% CI: 1.24-5.59). CONCLUSIONS: In the largest Canadian youth ice hockey longitudinal cohort to date, female players (despite policy disallowing bodychecking), players participating in lower levels of play, and those with an injury or concussion history had higher rates of concussion. Goalies and players in leagues that disallowed bodychecking had lower rates. Policy prohibiting bodychecking remains an effective concussion prevention strategy in youth ice hockey.

Knee- and Overall Health-Related Quality of Life Following Anterior Cruciate Ligament Injury: A Cross-sectional Analysis of Australian and Canadian Cohorts.

OBJECTIVE: To describe the knee- and overall health-related quality of life (QOL) 3 to 12 years after anterior cruciate ligament (ACL) tear, and to assess the association of clinical and structural features with QOL after ACL tear. DESIGN: Cross-sectional analysis of combined data from Australian (n = 76, 5.4 years postinjury) and Canadian (n = 50, 6.6 years postinjury) prospective cohort studies. METHODS: We conducted a secondary analysis of patient-reported outcomes and index knee magnetic resonance imaging (MRI) acquired in 126 patients (median 5.5 [range: 4-12] years postinjury), all treated with ACL reconstruction. Outcomes included knee (ACL Quality of Life questionnaire [ACL-QOL]) and overall health-related QOL (EQ-5D-3L). Explanatory variables were self-reported knee pain (Knee Injury and Osteoarthritis Outcome Score [KOOS-Pain subscale]) and function (KOOS-Sport subscale), and any knee cartilage lesion (MRI Osteoarthritis Knee Score). Generalized linear models were adjusted for clustering between sites. Covariates were age, sex, time since injury, injury type, subsequent knee injuries, and body mass index. RESULTS: The median [range] ACL-QOL score was 82 [24-100] and EQ-5D-3L was 1.0 [-0.2 to 1.0]. For every 10-point higher KOOS-Sport score, the ACL-QOL score increased by 3.7 points (95% confidence interval [CI]: 1.7, 5.7), whereas there was no evidence of an association with the EQ-5D-3L (0.00 points, 95% CI: -0.02, 0.02). There were no significant association between KOOS-Pain and ACL-QOL (4.9 points, 95% CI: -0.1, 9.9) or EQ-5D-3L (0.05 points, 95% CI: -0.01, 0.11), respectively. Cartilage lesions were not associated with ACL-QOL (-1.2, 95% CI: -5.1, 2.7) or EQ-5D-3L (0.01, 95% CI: -0.01, 0.04). CONCLUSION: Self-reported function was more relevant for knee-related QOL than knee pain or cartilage lesions after ACL tear. Self-reported function, pain, and knee structural changes were not associated with overall health-related QOL. J Orthop Sports Phys Ther 2023;53(7):1-12. Epub: 8 June 2023. doi:10.2519/jospt.2023.11838.

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

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

Youth With a Sport-Related Knee Injury Exhibit Significant and Persistent Knee-Related Quality-of-Life Deficits at 12-Month Follow-up Compared to Uninjured Peers.

OBJECTIVE: We aimed to compare knee-related quality of life (QOL) between youth with and without an intra-articular, sport-related knee injury at baseline (≤4 months postinjury), 6-month, and 12-month follow-up, and assess the association between clinical outcomes and knee-related QOL. DESIGN: Prospective cohort study. METHODS: We recruited 86 injured and 64 uninjured youth (similar age, sex, sport). Knee-related QOL was assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) QOL subscale. Linear mixed models (95% confidence interval [CI]; clustered on sex and sport) compared KOOS QOL between study groups over the study period, considering sex-based differences. We also explored the association of injury type (anterior cruciate ligament [ACL]/meniscus injury or other), knee extensor strength (dynamometry), moderate-to-vigorous physical activity (accelerometer), intermittent knee pain (Intermittent and Constant Osteoarthritis Pain [ICOAP] measure), and fear of reinjury (17-item Tampa Scale of Kinesiophobia) with knee-related QOL. RESULTS: Participant median (range) age was 16.4 (10.9-20.1) years, 67% were female, and 56% of injuries were ACL ruptures. Injured participants had lower mean KOOS QOL scores at baseline (-61.05; 95% CI: -67.56, -54.53), 6-month (-41.37; 95% CI: -47.94, -34.80), and 12-month (-33.34; 95% CI: -39.86, -26.82) follow-up, regardless of sex. Knee extensor strength (6- and 12-month follow-up), moderate-to-vigorous physical activity (12-month follow-up), and ICOAP (all time points) were associated with KOOS QOL in injured youth. Additionally, having an ACL/meniscus injury and higher Tampa Scale of Kinesiophobia scores were associated with worse KOOS QOL in injured youth. CONCLUSION: Youth with a sport-related knee injury have significant, persistent knee-related QOL deficits at 12-month follow-up. Knee extensor strength, physical activity, pain, and fear of reinjury may contribute to knee-related QOL. JOSPT 2023;53(8):1-10. Epub: 20 June 2023. doi:10.2519/jospt.2023.11611.

Longitudinal trajectories of posttraumatic headache after pediatric mild traumatic brain injury.

OBJECTIVE: This prospective, longitudinal cohort study examined the trajectory, classification, and features of posttraumatic headache after pediatric mild traumatic brain injury. METHODS: Children (N = 213; ages 8.00 to 16.99 years) were recruited from two pediatric emergency departments <24 hours of sustaining a mild traumatic brain injury or mild orthopedic injury. At 10 days, three months, and six months postinjury, parents completed a standardized questionnaire that was used to classify premorbid and posttraumatic headache as migraine, tension-type headache, or not otherwise classified. Multilevel mixed effects models were used to examine posttraumatic headache rate, severity, frequency, and duration in relation to group, time postinjury, and premorbid headache, controlling for age, sex, and site. RESULTS: PTH risk was greater after mild traumatic brain injury than mild orthopedic injury at 10 days (odds ratio = 197.41, p < .001) and three months postinjury (odds ratio = 3.50, p = .030), especially in children without premorbid headache. Posttraumatic headache was more frequent after mild traumatic brain injury than mild orthopedic injury, ß (95% confidence interval) = 0.80 (0.05, 1.55). Groups did not differ in other examined headache features and classification any time postinjury. CONCLUSIONS: Posttraumatic headache risk increases after mild traumatic brain injury relative to mild orthopedic injury for approximately three months postinjury, but is not clearly associated with a distinct phenotype.

Protective equipment in youth ice hockey: are mouthguards and helmet age relevant to concussion risk?

OBJECTIVES: To compare the incidence rates and odds of concussion between youth ice hockey players based on mouthguard use and helmet age. MATERIALS AND METHODS: Within a 5-year longitudinal cohort (2013/2014 to 2017/2018) of male and female ice hockey players (ages 11-18; n=3330 players) in Alberta (Canada), we analysed the relationship of equipment and concussion in both a prospective cohort and nested case (concussion) control (acute musculoskeletal injury) approach. The prospective cohort included baseline assessments documenting reported mouthguard use (yes/sometimes, no use), helmet age (newer/<2 years old, older/≥2 years old) and important covariables (weight, level of play, position of play, concussion history, body checking policy), with weekly player participation throughout the season. The nested case-control component used injury reports to document equipment (mouthguard use, helmet age) and other information (eg, mechanism and type of injury) for the injury event. Multivariable mixed effects negative binomial regression (prospective cohort, incidence rate ratios (IRRs)) and multivariable mixed effects logistic regression (nested case-control, odds ratios (OR)) examined the association between equipment and concussion. RESULTS: Players who reported wearing a mouthguard had a 28% lower concussion rate (IRR=0.72, 95% CI 0.56 to 0.93) and 57% lower odds of concussion (OR=0.43, 95% CI 0.27 to 0.70) compared with non-wearers. There were no associations in the concussion rate (IRR=0.94, 95% CI 0.75 to 1.15) and odds (OR=1.16, 95% CI 0.73 to 1.86) between newer and older helmets. CONCLUSIONS: Wearing a mouthguard was associated with a lower concussion rate and odds. Policy mandating use should be considered in youth ice hockey. More research is needed to identify other helmet characteristics (eg, quality, fit) that could lower concussion risk.

Characterizing Factors Influencing Baseline Plasma Biomarkers for Sport-Related Concussion in Adolescents.

Abstract Developing objective measures to diagnose sport-related concussion (SRC) is a top priority, particularly in the pediatric context, given the vulnerability of the developing brain. While advances in SRC blood biomarkers are being made in adult populations, less data are available for adolescents. Clinical validation of blood biomarkers post-SRC will first require investigation in a healthy uninjured state. Further, rapid pubertal changes during adolescence may implicate possible interactions with circulating sex hormones and the menstrual cycle for females. This cross-sectional study aimed to characterize pre-injury plasma levels of glial fibrillary acidic protein (GFAP), neurofilament light (NF-L), ubiquitin C-terminal hydrolase-L1 (UCH-L1), total tau (T-tau), and phosphorylated tau-181 (P-tau-181), considering previous concussion, age, and sex in healthy adolescent sport participants. Possible associations with menstrual cycle phase and circulating sex hormone levels (i.e., progesterone, estradiol, testosterone) were also explored. Pre-injury blood samples were obtained from 149 healthy adolescents (48% female, ages 11-18) participating in a larger Surveillance in High Schools and Community Sports to Reduce Concussions and their Consequences (SHRed Concussions) multi-site longitudinal cohort study. Main outcomes were natural log (ln) transformed plasma GFAP, NF-L, UCH-L1, T-tau, and P-tau-181 concentrations, quantified on the Quanterix Simoa HD-X platform. Mixed-effects multi-variable linear regression was used to assess associations between biomarkers and self-reported previous concussion (yes/no), age (years), sex (male/female), objectively determined menstrual cycle phase (follicular/luteal), plasma progesterone, estradiol, and testosterone. Males had 19.8% lower UCH-L1 (ß = -0.221, 95% confidence interval [CI; -0.396, -0.046]), 18.9% lower GFAP (ß = -0.210, 95% CI [-0.352, -0.068]), and 21.8% higher P-tau-181 (ß = 0.197, 95% CI [0.048, 0.346]) compared with females, adjusting for age and previous concussion. GFAP decreased 9.5% with each 1-year increase in age, adjusting for previous concussion and sex (ß = -0.100, 95% CI [-0.152, -0.049]). No biomarkers were associated with a history of previous concussion. Exploratory investigations found no associations between biomarkers and menstrual cycle phase. Females displayed an age-adjusted negative association between T-tau and progesterone (ß = -0.010, 95% CI [-0.018, -0.002]), whereas males had a negative age-adjusted association between UCH-L1 and testosterone (ß = -0.020, 95% CI [-0.037, -0.002]). As such, age- and sex-specific reference intervals may be warranted for pediatric athlete populations prior to clinical validation of blood biomarkers for SRC. Additionally, hormonal associations highlight the need to consider puberty and development in adolescent studies. Overall, findings suggest these biomarkers are resilient to a history of previous concussion and menstrual cycle phase, supporting continued investigation in adolescent SRC.

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.

Who Does Not Respond to Injury Prevention Warm-up Programs? A Secondary Analysis of Trial Data From Neuromuscular Training Programs in Youth Basketball, Soccer, and Physical Education.

OBJECTIVES: To identify factors associated with nonresponse to neuromuscular training (NMT) warm-up programs among youth exposed to NMT warm-ups. METHODS: This is a secondary analysis of youth (aged 11-18 years) in the intervention groups of 4 randomized controlled trials in high school basketball, youth community soccer, and junior high school physical education. Youth who were exposed to NMT and who sustained an injury during the study were considered nonresponders. Odds ratios (ORs) were based on generalized estimating equations logistic regression controlling for clustering by team/class and adjusted for age, weight, height, balance performance, injury history, sex, and sport (soccer/basketball/physical education). RESULTS: A total of 1793 youth were included. Youth with a history of injury in the previous year had higher odds (OR = 1.64; 95% CI: 1.14, 2.37) of injury during the study, and females were more likely (OR = 1.67; 95% CI: 1.21, 2.31) to sustain an injury than males who were participating in NMT. Age was not associated with the odds of sustaining an injury (OR = 1.10; 95% CI: 0.93, 1.30). Soccer players benefited most from greater adherence, with 81% lower odds of injury (OR = 0.19; 95% CI: 0.06, 0.57) when completing 3 NMT sessions a week compared with 1 session per week. CONCLUSION: Factors associated with nonresponse to an NMT warm-up program were female sex, history of injury during the previous 12 months, and lower weekly NMT session adherence in some sports (soccer). J Orthop Sports Phys Ther 2023;53(2):94-102. Epub: 9 December 2022. doi:10.2519/jospt.2022.11526.

Social determinants of participant recruitment and retention in a prospective cohort study of pediatric mild traumatic brain injury.

Background: Prior studies have shown poor recruitment and retention of minoritized groups in clinical trials. Objective: To examine several social determinants as predictors of consent to participate and retention as part of a prospective, longitudinal cohort study of children 8-16 with either mild traumatic brain injury (mild TBI) or orthopedic injury (OI). Methods: Children and families were recruited during acute visits to emergency departments (ED) in two large children's hospitals in the midwestern United States for a prospective, longitudinal cohort study of children 8-16 with either mild TBI or OI. Results: A total of 588 (mild TBI = 307; OI = 281) eligible children were approached in the ED and 315 (mild TBI = 195; OI = 120) were consented. Children who consented did not differ significantly from those who did not consent in sex or age. Consent rates were higher among Black (60.9%) and multi-racial (76.3%) children than white (45.3%) children. Among the 315 children who consented, 217 returned for a post-acute assessment (mild TBI = 143; OI = 74), a retention rate of 68.9%. Participants who were multi-racial (96.6%) or white (79.8%) were more likely to return for the post-acute visit than those who were Black (54.3%). Conclusions: Racial differences exist in both recruitment and retention of participants in a prospective, longitudinal cohort of children with mild TBI or OI. Further work is needed to understand these differences to ensure equitable participation of minoritized groups in brain injury research.

Pregnancy Outcome in Women Exposed to Metal Fume in Welding: A Canadian Cohort Study.

OBJECTIVES: Welding is a physically demanding job that entails exposure to metal fume and particles. There is little information on the effect of welding exposures on the outcome of a pregnancy conceived during a period when a woman was employed as a welder. METHODS: Women welders recruited to the Workers Health in Apprenticeship Trades-Metal and Electrical (WHAT-ME) study were followed-up every 6 months for up to 5 years (January 2011-August 2018), and every pregnancy recorded. At the first 6-month follow-up, a detailed questionnaire was completed for the most recent day in welding, and this information was collected again at each follow-up and also from questionnaires completed during pregnancy. The date of conception was estimated for each pregnancy and the job at that date identified. Exposures to ergonomic factors, work schedule and perceptions of noise, heat and cold were extracted for the job at conception. Exposures to metals (aluminum, chromium, manganese, and nickel) and particles in welding fume were estimated from previously validated exposure algorithms reflecting the welding process, base metal and consumables of the job at the conception date. The effects of exposures were estimated in multilevel multivariable models allowing for confounding. RESULTS: There were 242 pregnancies conceived by a welder working in her trade, 87 were before the first follow-up, 3 were after first follow-up but detailed information was not collected, 22 of those potentially included in the assessment group were in-trade but not welding leaving 122 pregnancies in 90 welders for analysis. Of these 91 resulted in a live birth and 31 in a fetal loss (27 miscarriages and 4 stillbirths). Mean birth weight for live births was 3365 g and gestation 39.4 weeks. Final models showed that risk of fetal loss increased with manipulating heavy objects [odds ratio (OR) = 5.13, 95% confidence interval (CI) 2.04-12.92], whole-body vibration (OR = 5.86, 95% CI 1.81-18.92), a higher rating for noise exposure intensity (OR = 1.52, 95% CI 1.24-1.85), and decreased with use of local exhaust ventilation (OR = 0.20, 95% CI 0.03-1.18). Gestation decreased with perceived heat intensity (ß = -0.15, 95% CI -0.29 to -0.02) and number of previous pregnancies (ß = -0.35, 95% CI -0.65 to -0.05). Birth weight was lower in those reporting whole-body vibration (ß = -596 g, 95% CI -924 to -267) and increased with the welder's body mass index (ß = 36 g, 95% CI 12-61). Estimates of exposure to metals and particles were unrelated to gestation or birth weight. In a bivariate analysis, allowing for the same welder reporting >1 pregnancy, estimated airborne aluminum exposure (and to a lesser degree exposure to nickel and particles) was related to greater risk of fetal loss (OR = 1.52, 95% CI 1.04-2.24) but neither aluminum nor the other estimated elements of welding fume added to the final model. CONCLUSIONS: In this group of women actively engaged in welding during the time surrounding conception, the outcome of pregnancy was strongly related to work exposures, particularly vibration (reported in grinding tasks), manipulation of heavy objects, and perceived intensity of noise and heat. The study was unable to show an independent effect of exposure to metal fume constituents.

Urinary Metals as a Marker of Exposure in Men and Women in the Welding and Electrical Trades: A Canadian Cohort Study.

OBJECTIVES: Men and women working in the welding trades undergo the same apprenticeship training but it is unknown whether, once in the trade, their exposures differ. Comparison of urinary metal concentrations, having adjusted for estimated airborne exposure, may provide an answer. METHODS: Men and women were recruited to a cohort study of workers in the welding and electrical trades (the Workers Health in Apprenticeship Trades-Metal working and Electrical [WHAT-ME study]). They completed a recruitment questionnaire and further questionnaires every 6 months for up to 5 years. At each follow-up, they gave details on employment and, if welding, answered trade-specific questionnaires. Urine samples were collected by mail. Welding exposure matrices were developed to estimate metal exposures from welding process, base metal, and consumables. Urinary metal concentrations, determined by ICP-MS, were compared by trade (welding or electrical). Within welding, the relation of urinary concentrations to estimated airborne exposure was examined, with adjustment for potential confounders including sex, use of respiratory protective equipment (RPE), and time spent outdoors. Natural logarithms were taken of exposure estimates and urinary concentrations, to reduce skew. All regression analyses included creatinine concentration. RESULTS: Urinary metal concentrations were analysed for 12 metals in 794 samples. Antimony, arsenic, lead, and mercury had a high proportion of samples with no metal detected and were not considered further. The urinary concentrations of aluminum, cadmium, chromium, cobalt, copper, manganese, nickel, and zinc were compared for welders (434 samples) and electrical workers (360). After adjustment for potential confounders, welders had higher urinary concentrations for aluminum (ß = 0.13 95%CI 0.03-0.24) and chromium (ß = 0.66 95%CI 0.55-0.77). Of 434 welder urines, 334 could be matched securely to detailed information about the most recent day welding. For these, an estimate of airborne exposure was made for aluminum, chromium, manganese, and nickel. Male welders were estimated to have higher airborne exposure to chromium and nickel than women welders. No difference was seen in the estimated exposures for aluminum or manganese (or total dust). Regression analyses of the relation of urinary metals to estimated exposure showed a good concordance for aluminum (ß = 0.09 95%CI 0.04-0.15 (P < 0.001) and chromium (ß = 0.11 95%CI 0.05-0.17 P < 0.001). The concordance for manganese and nickel was positive, but much weaker. Urinary concentrations of aluminum and nickel were somewhat lower with increasing time wearing RPE and, for chromium and nickel, with time working outdoors. Having adjusted for estimated exposure, creatinine and other confounders, male welders had lower urine concentrations of aluminum (ß = -0.35 95%CI -0.51 to -0.19 P < 0.001) chromium (ß = -0.38 95%CI -0.57 to -0.19 P < 0.001) and manganese (ß = -0.36 95%CI -0.49 to -0.23 P < 0.001) than female welders. CONCLUSION: Welders had higher urinary concentrations of aluminum and chromium than electrical workers. Exposure estimates of aluminum and chromium for welders were a valid representation of the airborne exposures to these metals. Although male welders were estimated to have higher exposures of chrome and nickel than female welders, the higher urinary metal concentrations in women welders is of concern, particularly for women who may conceive while in the trade.