Concussion Burden, Recovery, and Risk Factors in Elite Youth Ice Hockey Players.

OBJECTIVE: To examine rates of concussion and more severe concussion (time loss of greater than 10 days) in elite 13- to 17-year-old ice hockey players. METHODS: This is a prospective cohort study (Alberta, Canada). Bantam (13-14 years) and Midget (15-17 years) male and female elite (top 20% by division of play) youth ice hockey players participated in this study. Players completed a demographic and medical history questionnaire and clinical test battery at the beginning of the season. A previously validated injury surveillance system was used to document exposure hours and injury during one season of play (8 months). Players with a suspected ice hockey-related concussion were referred to the study sport medicine physicians for assessment. Time loss from hockey participation was documented on an injury report form. RESULTS: Overall, 778 elite youth ice hockey players (659 males and 119 females; aged 13-17 years) participated in this study. In total, 143 concussions were reported. The concussion incidence rate (IR) was 17.60 concussions/100 players (95% CI, 15.09-20.44). The concussion IR was 1.31 concussions/1000 player-hours (95% CI, 1.09-1.57). Time loss of greater than 10 days was reported in 74% of cases (106/143), and 20% (n = 28) had time loss of greater than 30 days. CONCLUSIONS: Concussion is a common injury in elite youth ice hockey players. In this study population, a large proportion of concussions (74%) resulted in a time loss of greater than 10 days, possibly reflecting more conservative management or longer recovery in youth athletes.

Jumper's Knee: A Prospective Evaluation of Risk Factors in Volleyball Players Using a Novel Measure of Injury.

OBJECTIVES: To examine potential intrinsic risk factors that may contribute to the onset of jumper's knee in elite level-male volleyball players. DESIGN: Prospective Cohort Study. SETTING: Varsity and National team volleyball gymnasiums. PARTICIPANTS: Sixty elite adult male volleyball players from Canada. ASSESSMENT OF RISK FACTORS: Players completed a series of risk factor assessments at the commencement of their seasons, including vertical jump (cm), ankle dorsiflexion range (degrees), dynamic balance (normalized distance reached; cm), dynamic knee alignment (degrees), and landing mechanics (degrees). MAIN OUTCOME MEASURE: Self-reported knee problems, captured via short message service. RESULTS: Knee problem prevalence was 75% [95% confidence intervals (CIs): 62.2-84.6] and the incidence rate for substantial injuries over the study period was 30 injuries/100 players/season (95% CI: 19.5-43.1). No risk factor was found to significantly predict the future occurrence of developing jumper's knee. The odds ratios were close to unity (range: 0.94-1.07) with narrow confidence intervals and P > 0.05. CONCLUSIONS: A more sensitive capture of overuse knee problems did not result in the identification of distinct risk factors for the development of jumper's knee. These findings highlight a lack of available methodology to accurately assess risk factors for overuse injuries.

Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment.

SYNOPSIS: The risk factors of concussion may be categorized as intrinsic (internal factors specific to the individual) or extrinsic (external factors related to the environment or sport). Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. In most cases, the symptoms of concussion resolve in the initial few days following the injury, and a strategy involving a gradual return to sport and school is recommended. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. J Orthop Sports Phys Ther 2019;49(11):799-810. doi:10.2519/jospt.2019.8926.

The Effect of Injury Definition and Surveillance Methodology on Measures of Injury Occurrence and Burden in Elite Volleyball.

A time-loss injury definition continues to be the most widely used injury definition despite evidence that it fails to accurately capture overuse injuries. An overuse injury questionnaire, using an "all complaints" definition has been created to address the limitation of a time-loss definition. The main aim of this work was to determine the effect that injury definition and registration methodology has on the collection of knee injuries among elite level volleyball players. To reach this goal, seventy-two volleyball players were prospectively followed over 32-weeks. Time-loss injuries were captured using an individual injury report form (IIRF). Study participants completed an overuse injury questionnaire (mOIQ) via a weekly short message service (SMS). The IIRF captured 15 time-loss knee injuries in 72 study participants (20%). Based on the mOIQ, 84.7% of participants reported having a knee problem and 66.7% sustained a substantial knee problem. All IIRF knee injuries captured were also registered by the mOIQ. Agreement on the specific diagnosis occurred for 66.7% of injuries resulting in a moderate Kappa score of 0.51. In conclusion, an overuse injury questionnaire provided a greater understanding of the magnitude and burden of knee injuries in this population.

Changes in Measures of Cervical Spine Function, Vestibulo-ocular Reflex, Dynamic Balance, and Divided Attention Following Sport-Related Concussion in Elite Youth Ice Hockey Players.

BACKGROUND: Concussion is a commonly occurring injury. The extent to which the cervical spine, vestibulo-ocular reflex (VOR), dynamic balance, and divided attention are affected following concussion is not well understood. OBJECTIVES: To evaluate acute changes in measures of (1) cervical spine function, (2) VOR function, (3) dynamic balance, and (4) tasks of divided attention in elite youth ice hockey players following a sport-related concussion. METHODS: In this prospective cohort study, elite 13- to 17-year-old ice hockey players completed cervical spine measures (cervical flexor endurance test, head perturbation test, anterolateral strength, cervical flexion rotation test, joint position error), VOR function tests (head thrust test, dynamic visual acuity [clinical and computerized]), dynamic balance tests (Functional Gait Assessment), and divided-attention tasks (walking-while-talking test) both in the preseason and following concussion. RESULTS: At least 1 test was completed by 69 of 97 (71%) players (a maximum of 55 for any 1 test) at both preseason and immediately following concussion (median, 4 days post concussion). After Bonferroni corrections (α = .00625), using Wilcoxon signed-rank tests, cervical spine measures were significantly worse following concussion compared to baseline (cervical flexor endurance test: z = -5.20, P<.001; anterolateral neck strength: zleft = -5.36, P<.001 and zright = -5.45, P<.001; and head perturbation test: z = -4.36, P<.001). Time taken to complete a complex task of divided attention relative to normal walking speed was faster (improved) compared to the preseason (z = -2.59, P<.01). There was no change in VOR or dynamic balance following concussion. CONCLUSION: Measures of cervical spine function and divided attention were altered following concussion. However, tests of VOR and dynamic balance were not significantly different from baseline. Future research to evaluate the mechanism underlying these changes is warranted. J Orthop Sports Phys Ther 2018;48(12):974-981. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8258.

The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport.

The purpose of this paper is to summarise the methodology for the 5th International Consensus Conference on Concussion in Sport. The 18 months of preparation included engagement of a scientific committee, an expert panel of 33 individuals in the field of concussion and a modified Delphi technique to determine the primary questions to be answered. The methodology also involved the writing of 12 systematic reviews to inform the consensus conference and submission and review of scientific abstracts. The meeting itself followed a 2-day open format, a 1-day closed expert panel meeting and two additional half day meetings to develop the Concussion Recognition Tool 5 (Pocket CRT5), Sport Concussion Assessment Tool 5 (SCAT5) and Child SCAT5.

Validation of an inertial measurement unit for the measurement of jump count and height.

OBJECTIVES: To validate the use of an inertial measurement unit (IMU) for the collection of total jump count and assess the validity of an IMU for the measurement of jump height against 3-D motion analysis. DESIGN: Cross sectional validation study. SETTING: 3D motion-capture laboratory and field based settings. PARTICIPANTS: Thirteen elite adolescent volleyball players. INDEPENDENT VARIABLES: Participants performed structured drills, played a 4 set volleyball match and performed twelve counter movement jumps. MAIN OUTCOME MEASURES: Jump counts from structured drills and match play were validated against visual count from recorded video. Jump height during the counter movement jumps was validated against concurrent 3-D motion-capture data. RESULTS: The IMU device captured more total jumps (1032) than visual inspection (977) during match play. During structured practice, device jump count sensitivity was strong (96.8%) while specificity was perfect (100%). The IMU underestimated jump height compared to 3D motion-capture with mean differences for maximal and submaximal jumps of 2.5 cm (95%CI: 1.3 to 3.8) and 4.1 cm (3.1-5.1), respectively. CONCLUSION: The IMU offers a valid measuring tool for jump count. Although the IMU underestimates maximal and submaximal jump height, our findings demonstrate its practical utility for field-based measurement of jump load.

Psychosocial Outcomes of Sport Concussions in Youth Hockey Players.

The objective is to evaluate the psychological outcomes arising from sport concussions. Participants included AA and AAA level Bantam and Midget hockey players (n = 672) between 12 and 17 years of age (mean = 15.0 years; SD = 1.2) enrolled in a large cohort study. All participants completed baseline tests including the Behavior Assessment System for Children, 2nd Edition (BASC2) and a pre-season medical questionnaire (PSQ) completed by parents that included a retrospective report of prior concussions and injuries. Players were assigned to 4 groups: no injury (NONE), concussion (CO) and musculoskeletal (MSK) injuries or both (COMB). Participants in the CO and COMB groups demonstrated significantly higher rates of psychological difficulties compared with other groups [F(63, 1800) = 1.43, p = .016, partial η(2) = 0.05) and on select clinical scales measuring atypicality, locus of control, anxiety, depression, sense of inadequacy, somatization, and attention. In addition, results from the composite clinical scales reached statistical significance for internalizing problems and emotional symptom index. Effect sizes were minimal with the exception of comparisons between the NONE and COMB groups where effect sizes were medium to large. Proportions above clinical cut-off scores set by the BASC2 were higher for the COMB group compared with CO, MSK, or NONE groups. Results suggest smaller percentage of youth may be more prone to psychological sequelae following concussion.

The impact of concussion on cardiac autonomic function: A systematic review.

PRIMARY OBJECTIVE: To evaluate the evidence regarding the effect of concussion on cardiac autonomic function (CAF). INCLUSION CRITERIA: Original research; available in English; included participants with concussion or mild traumatic brain injury (mTBI) and a comparison group; included measures of heart rate (HR) and/or heart rate variability (HRV) as outcomes. Studies of humans (greater than 6 years old) and animals were included. Critical appraisal tools: The Downs and Black (DB) criteria and Structured Effectiveness Quality Evaluation Scale (SEQES). RESULTS: Nine full-length articles and four abstracts were identified. There is conflicting evidence regarding CAF at rest following concussion. There is evidence of elevated HR and reduced HRV with low-intensity, steady-state exercise up to 10 days following concussion. There was no significant difference in HRV during isometric handgrip testing or HR while performing cognitive tasks following concussion. The validity of current literature is limited by small sample sizes, lack of female or paediatric participants, methodological heterogeneity and lack of follow-up. CONCLUSIONS: While there is some evidence to suggest CAF is altered during physical activity following concussion, methodological limitations highlight the need for further research. Understanding the effect of concussion on CAF will contribute to the development of more comprehensive concussion management strategies.

Policy change eliminating body checking in non-elite ice hockey leads to a threefold reduction in injury and concussion risk in 11- and 12-year-old players.

BACKGROUND: In ice hockey, body checking is associated with an increased risk of injury. In 2011, provincial policy change disallowed body checking in non-elite Pee Wee (ages 11-12 years) leagues. OBJECTIVE: To compare the risk of injury and concussion between non-elite Pee Wee ice hockey players in leagues where body checking is permitted (2011-12 Alberta, Canada) and leagues where policy change disallowed body checking (2011-12 Ontario, Canada). METHOD: Non-elite Pee Wee players (lower 70%) from Alberta (n=590) and Ontario (n=281) and elite Pee Wee players (upper 30%) from Alberta (n=294) and Ontario (n=166) were recruited to participate in a cohort study. Baseline information, injury and exposure data was collected using validated injury surveillance. RESULTS: Based on multiple Poisson regression analyses (adjusted for clustering by team, exposure hours, year of play, history of injury/concussion, level of play, position and body checking attitude), the incidence rate ratio (IRR) associated with policy allowing body checking was 2.97 (95% CI 1.33 to 6.61) for all game injury and 2.83 (95% CI 1.09 to 7.31) for concussion. There were no differences between provinces in concussion [IRR=1.50 (95% CI 0.84 to 2.68)] or injury risk [IRR=1.22 (95% CI 0.69 to 2.16)] in elite levels of play where both provinces allowed body checking. CONCLUSIONS: The rate of injury and concussion were threefold greater in non-elite Pee Wee ice hockey players in leagues where body checking was permitted. The rate of injury and concussion did not differ between provinces in elite levels, where body checking was allowed.

Incidence, mechanism and risk factors for injury in youth rock climbers.

BACKGROUND: Rock-climbing participation has grown globally in recent years, and the sport was officially recognised by the International Olympic Committee in 2010. The epidemiology of climbing injuries in adults has been examined, but few studies have investigated injury in youth climbers. OBJECTIVE: To examine the incidence, mechanisms and risk factors for injury in recreational and elite sport climbers and boulderers aged 11-19 years. STUDY DESIGN: Cross-sectional. METHODS: Youth (n=116) were recruited from climbing facilities across Alberta, Canada. Participants completed an anonymous questionnaire from October 2012 to March 2013. Climbing injury incidence proportions and incidence rates (IR) were calculated. ORs with corresponding 95% CIs were estimated for possible risk factors. RESULTS: The injury IR was 4.44 injuries/1000 climbing hours (95% CI 3.74 to 5.23). Sprains (27%) and strains (26%) were the predominant injury types, and repetitive overuse was the primary mechanism of injury (42%). Hands and fingers were the most commonly injured locations (21%). Exploratory analyses showed three risk factors for injury: older age (15-19 vs 11-14 years; OR=11.30, 95% CI 2.33 to 54.85), injury in a sport other than climbing (OR=6.46, 95% CI 1.62 to 25.68) and preventive taping (OR=5.09, 95% CI 1.44 to 18.02). CONCLUSIONS: Injury risk is high in youth climbers. Findings are consistent with the reported rates, types and mechanisms in adults. Modifiable risk factors warrant further investigation to inform the development of injury prevention strategies, targeting high-risk climbers including adolescents and those with previous injury.

Smartphone and tablet apps for concussion road warriors (team clinicians): a systematic review for practical users.

BACKGROUND: Mobile technologies are steadily replacing traditional assessment approaches for the recognition and assessment of a sports concussion. Their ease of access, while facilitating the early identification of a concussion, also raises issues regarding the content of the applications (apps) and their suitability for different user groups. AIM: To locate and review apps that assist in the recognition and assessment of a sports concussion and to assess their content with respect to that of internationally accepted best-practice instruments. METHODS: A search of international app stores and of the web using key terms such as 'concussion', 'sports concussion' and variants was conducted. For those apps meeting the inclusion criteria, data were extracted on the platform, intended users and price. The content of each app was benchmarked to the Sport Concussion Assessment Tool 2 (SCAT2) and Pocket SCAT2 using a custom scoring scheme to generate a percentage compliance statistic. RESULTS: 18 of the 155 apps identified met the inclusion criteria. Almost all (16/18) were available on an iOS platform and only five required a payment to purchase. The apps were marketed for a wide range of intended users from medical professionals to the general public. The content of the apps varied from 0% to 100% compliance with the selected standard, and 'symptom evaluation' components demonstrated the highest level of compliance. CONCLUSIONS: The surge in availability of apps in an unregulated market raises concerns as to the appropriateness of their content for different groups of end users. The consolidation of best-practice concussion instruments now provides a framework to inform the development of future apps.

A systematic video analysis of National Hockey League (NHL) concussions, part I: who, when, where and what?

BACKGROUND: Although there is a growing understanding of the consequences of concussions in hockey, very little is known about the precipitating factors associated with this type of injury. AIM: To describe player characteristics and situational factors associated with concussions in the National Hockey League (NHL). METHODS: Case series of medically diagnosed concussions for regular season games over a 3.5-year period during the 2006-2010 seasons using an inclusive cohort of professional hockey players. Digital video records were coded and analysed using the Heads Up Checklist. RESULTS: Of 197 medically diagnosed concussions, 88% involved contact with an opponent. Forwards accounted for more concussions than expected compared with on-ice proportional representation (95% CI 60 to 73; p=0.04). Significantly more concussions occurred in the first period (47%) compared with the second and third periods (p=0.047), with the majority of concussions occurring in the defensive zone (45%). Approximately 47% of the concussions occurred in open ice, 53% occurred in the perimeter. Finally, 37% of the concussions involved injured players' heads contacting the boards or glass. CONCLUSIONS: This study describes several specific factors associated with concussions in the NHL, including period of the game, player position, body size, and specific locations on the ice and particular situations based on a player's position.

A systematic video analysis of National Hockey League (NHL) concussions, part II: how concussions occur in the NHL.

BACKGROUND: Concussions in sports are a growing cause of concern, as these injuries can have debilitating short-term effects and little is known about the potential long-term consequences. This work aims to describe how concussions occur in the National Hockey League. METHODS: Case series of medically diagnosed concussions for regular season games over a 3.5-year period during the 2006-2010 seasons. Digital video records were coded and analysed using a standardised protocol. RESULTS: 88% (n=174/197) of concussions involved player-to-opponent contact. 16 diagnosed concussions were a result of fighting. Of the 158 concussions that involved player-to-opponent body contact, the most common mechanisms were direct contact to the head initiated by the shoulder 42% of the time (n=66/158), by the elbow 15% (n=24/158) and by gloves in 5% of cases (n=8/158). When the results of anatomical location are combined with initial contact, almost half of these events (n=74/158) were classified as direct contact to the lateral aspect of the head. CONCLUSIONS: The predominant mechanism of concussion was consistently characterised by player-to-opponent contact, typically directed to the head by the shoulder, elbow or gloves. Also, several important characteristics were apparent: (1) contact was often to the lateral aspect of the head; (2) the player who suffered a concussion was often not in possession of the puck and (3) no penalty was called on the play.

Advancing the preparticipation physical evaluation (PPE): an ACSM and FIMS joint consensus statement.

While the preparticipation physical evaluation (PPE) is widely accepted, its usage and content are not standardized. Implementation is affected by cost, access, level of participation, participant age/sex, and local/regional/national mandate. PPE screening costs are generally borne by the athlete, family, or club. Screening involves generally agreed-upon questions based on expert opinion and tested over decades of use. No large-scale prospective controlled tracking programs have examined PPE outcomes. While the panel did not reach consensus on electrocardiogram screening as a routine part of PPE, all agreed that a history and physical exam focusing on cardiac risk is essential, and an ECG should be used where risk is increased. The many areas of consensus should help the American College of Sports Medicine and the Fédération Internationale du Médicine du Sport in developing a universally accepted PPE. An electronic PPE, using human-centered design, would be comprehensive, would provide a database given that PPE is mandatory in many locations, would simplify PPE administration, would allow remote access to clinical data, and would provide the much-needed data for prospective studies in this area.

Advancing the preparticipation physical evaluation: an ACSM and FIMS joint consensus statement.

: While the preparticipation physical evaluation (PPE) is widely accepted, its usage and content are not standardized. Implementation is affected by cost, access, level of participation, participant age/sex, and local/regional/national mandate. Preparticipation physical evaluation screening costs are generally borne by the athlete, family, or club. Screening involves generally agreed-upon questions based on expert opinion and tested over decades of use. No large-scale prospective controlled tracking programs have examined PPE outcomes. While the panel did not reach consensus on electrocardiogram (ECG) screening as a routine part of PPE, all agreed that a history and physical exam focusing on cardiac risk is essential, and an ECG should be used where risk is increased. The many areas of consensus should help the American College of Sports Medicine and Fédération Internationale du Médicine du Sport in developing a universally accepted PPE. An electronic PPE, using human-centered design, would be comprehensive, would provide a database given that PPE is mandatory in many locations, would simplify PPE administration, would allow remote access to clinical data, and would provide the much-needed data for prospective studies in this area.

The IOC Centres of Excellence bring prevention to sports medicine.

The protection of an athlete's health and preventing injuries and illnesses in sport are top priorities for the IOC and its Medical Commission. The IOC therefore partners with selected research centres around the world and supports research in the field of sports medicine. This has enabled the IOC to develop an international network of expert scientists and clinicians in sports injury and disease prevention research. The IOC wants to promote injury and disease prevention and the improvement of physical health of the athlete by: (1) establishing long-term research programmes on injury and disease prevention (including studies on basic epidemiology, risk factors, injury mechanisms and intervention), (2) fostering collaborative relationships with individuals, institutions and organisations to improve athletes' health, (3) implementing and collaborating with applied, ongoing and novel research and development within the framework and long-term strategy of the IOC and (4) setting up knowledge translation mechanisms to share scientific research results with the field throughout the Olympic Movement and sports community and converting these results into concrete actions to protect the health of the athletes. In 2009, the IOC also identified four research centres that had an established track record in research, educational and clinical activities to achieve these ambitions: (1) the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Australia; (2) the Sport Injury Prevention Research Centre (SIPRC), Canada; (3) the Clinical Sport and Exercise Medicine Research (CSEM), South Africa and (4) the Oslo Sports Trauma Research Center (OSTRC), Norway. This paper highlights the work carried out by these four IOC Centres of Excellence over the past 6 years and their contribution to the world of sports medicine.

Reality check: the cost-effectiveness of removing body checking from youth ice hockey.

BACKGROUND/AIM: The risk of injury among Pee Wee (ages 11-12 years) ice hockey players in leagues that allow body checking is threefold greater than in leagues that do not allow body checking. We estimated the cost-effectiveness of a no body checking policy versus a policy that allows body checking in Pee Wee ice hockey. METHODS: Cost-effectiveness analysis alongside a prospective cohort study during the 2007-2008 season, including players in Quebec (n=1046), where policy did not allow body checking, and in Alberta (n=1108), where body checking was allowed. Injury incidence rates (injuries/1000 player-hours) and incidence proportions (injuries/100 players), adjusted for cluster using Poisson regression, allowed for standardised comparisons and meaningful translation to community stakeholders. Based on Alberta fee schedules, direct healthcare costs (physician visits, imaging, procedures) were adjusted for cluster using bootstrapping. We examined uncertainty in our estimates using cost-effectiveness planes. RESULTS: Associated with significantly higher injury rates, healthcare costs where policy allowed body checking were over 2.5 times higher than where policy disallowed body checking ($C473/1000 player-hours (95% CI $C358 to $C603) vs $C184/1000 player-hours (95% CI $C120 to $C257)). The difference in costs between provinces was $C289/1000 player-hours (95% CI $C153 to $C432). Projecting results onto Alberta Pee Wee players registered in the 2011-2012 season, an estimated 1273 injuries and $C213 280 in healthcare costs would be avoided during just one season with the policy change. CONCLUSION: Our study suggests that a policy disallowing body checking in Pee Wee ice hockey is cost-saving (associated with fewer injuries and lower costs) compared to a policy allowing body checking. As we did not account for long-term outcomes, our results underestimate the economic impact of these injuries.