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Concerns around concussion highlight the need for strategies to improve the implementation and translation of concussion guidelines in community sports. This study assessed players' utilisation and compliance with New Zealand Rugby's Concussion Management Pathway (CMP). This pragmatic, mixed methods study comprised of concussion injury surveillance and mapping of players' healthcare touchpoints through the CMP. Semi-structured interviews were conducted to understand stakeholders' experiences. Over the season, 27 different healthcare pathways were identified with 28% of players progressing through all phases of the CMP (ideal pathway). Of the 206 suspected concussions reported over the season, 70% were logged in the CMP phone App, and 89% of these had an associated valid baseline concussion assessment. Prior to returning to contact training, 64% of players obtained a medical clearance. One theme, 'belief in the value of pathway' was identified as a facilitator across all CMP components. Themes such as 'concussion knowledge and the nature of concussion'; 'communication between stakeholders and sufficient information on the process'; and 'strong relationships and clarity around responsibilities' were identified as facilitators across several pathway components. Other facilitators included 'ease and timing of general practitioner access'; 'the phone App as facilitator to logging'; and 'spotting for concussion as a team'. Additionally, the findings signify baseline testing as a potential pre-cursor to overall CMP compliance. Strategies that support the facilitators identified in this study may further enhance compliance., (© 2024 The Author(s). European Journal of Sport Science published by Wiley‐VCH GmbH on behalf of European College of Sport Science.)

Context: Understanding former professional football players engagement with health promoting behaviors (physical exercise, high quality diet, and good sleep hygiene) will be helpful for developing lifestyle interventions to improve their feelings of well-being, a relatively understudied facet of health among this population., Objective: Examine associations among health-promoting behaviors and subjective outcomes related to well-being among former National Football League (NFL) players., Design: Cross-sectional., Setting: Online or hard-copy survey., Patients or Other Participants: Former NFL players., Main Outcome Measures: Self-reported health-promoting behaviors (exercise frequency, diet quality, sleep duration and disturbance) and factors related to well-being (PROMIS ® Meaning and Purpose [MP], Self-Efficacy [SE], Ability to Participate in Social Roles and Activities [SRA]). Multivariable linear regression models were fit for each well-being-related factor with health-promoting behaviors as explanatory variables alongside select demographic, behavioral, and functional covariates. Models were fit for the full sample and separately for individual age groups: <30 years; 30-39 years; 40-49 years; 50-59 years; 60-69 years; and 70+ years., Results: A total of 1,784 former NFL players (aged 52.3±16.3 years) completed the survey. Lower sleep disturbance was associated with better MP (β[standard error]=-0.196[0.024]), SE (β[standard error]=-0.185[0.024]), and SRA (β[standard error]=-0.137[0.017]) in the full sample and almost all the individual age groups. More frequent moderate-to-vigorous exercise was associated with higher MP (β[standard error]=0.068[0.025]) and SRA (β[standard error]=0.151[0.065]) in the full sample, and with better MP, SE, and SRA among select middle-aged groups (between 40-69 years old). Diet quality, resistance training exercise frequency, other wellness activity frequency, and sleep duration were not associated with well-being-related factors in the full-group and sparse significant associations were observed in individual age group models., Conclusions: Lower sleep disturbance and more frequent moderate-to-vigorous exercise frequency may be important targets for improving overall health and well-being among former NFL players.

Determining whether repetitive head impacts (RHI) cause the development of chronic traumatic encephalopathy (CTE)-neuropathological change (NC) and whether pathological changes cause clinical syndromes are topics of considerable interest to the global sports medicine community. In 2022, an article was published that used the Bradford Hill criteria to evaluate the claim that RHI cause CTE. The publication garnered international media attention and has since been promoted as definitive proof that causality has been established. Our counterpoint presents an appraisal of the published article in terms of the claims made and the scientific literature used in developing those claims. We conclude that the evidence provided does not justify the causal claims. We discuss how causes are conceptualised in modern epidemiology and highlight shortcomings in the current definitions and measurement of exposures (RHI) and outcomes (CTE). We address the Bradford Hill arguments that are used as evidence in the original review and conclude that assertions of causality having been established are premature. Members of the scientific community must be cautious of making causal claims until the proposed exposures and outcomes are well defined and consistently measured, and findings from appropriately designed studies have been published. Evaluating and reflecting on the quality of research is a crucial step in providing accurate evidence-based information to the public., (© 2024. The Author(s).)

Previous studies on pain experiences in retired contract sport athletes have been cross-sectional, leaving gaps in our understanding of the evolution of pain interference (PI) and factors that influence trajectories decades after sport discontinuation. This study investigated the longitudinal course of PI in former male National Football League (NFL) players over a 19-year period following sport discontinuation and examined factors influencing overall levels and trajectories of PI. Former NFL players completed health surveys in 2001, 2010, and 2019, with PI ratings measured using the 36-Item Short Form Health Survey (2001 and 2010) and the Patient-Reported Outcomes Measurement Information System (2019). Unconditional latent growth curve models analyzed overall PI severity and trajectories. Conditional latent growth curve models explored the influence of musculoskeletal injuries, osteoarthritis (OA), and depression diagnosis on PI. Over 19 years (N = 338; mean age = 48.96 ± 9.35), PI significantly increased (slope = .179, P < .001; mean Patient-Reported Outcomes Measurement Information System PI t-scores 2001 = 54.19, 2010 = 54.64, 2019 = 57.38). Cumulative musculoskeletal injuries (B = .092, P < .001) and baseline depression diagnosis (B = 4.463, P < .001) were associated with overall PI levels but not change over time. OA was significantly associated with overall PI levels (B = 6.536, P < .001) and trajectory (B = -.253, P < .001); those endorsing OA in 2001 had lower PI increases over 19 years. The body region of injury and level of play during injuries mirrored overall injury effects. PI mildly increased over 19 years, with multiple factors independently influencing overall PI levels. Enhancing former contact sport athletes' daily functionality may be achieved through holistic biopsychosocial interventions addressing musculoskeletal injuries, OA, and depression. Future research should identify factors influencing elevated trajectories of long-term PI post-sport discontinuation. PERSPECTIVE: This study assessed PI in former NFL athletes over 2 decades, revealing notable interindividual variability in trajectories over time. Musculoskeletal injuries, depression, and OA correlated with overall PI. Prevention and intervention in these 3 areas present the potential to improve disruptions in daily living due to pain in former athletes., Competing Interests: Disclosures This study (NFL-LONG) was funded by the National Football League (NFL). Dr. Brett reports grants from the National Institute on Aging and the National Institute of Neurological Disorders and Stroke, and honoraria for conference presentations. Dr. Chandran discloses research funding from the National Collegiate Athletic Association as the Director of the NCAA Injury Surveillance Program, and separately from the Atlantic Coast Conference Center for Research on Intercollegiate Athletics, and the University of North Carolina Translational and Clinical Sciences Institute; he also discloses receiving honoraria from the Sports Neuropsychological Society as well as the American Medical Society for Sports Medicine. Dr. Kerr reports grants from the National Institutes of Health, the Centers for Disease Control and Prevention, and the National Football League. Dr. Lempke reports grants from the Eastern Athletic Trainers’ Association, National Athletic Trainers’ Association, and VALD. Dr. Walton reports grant funding from the U.S. Departments of Defense and Veterans Affairs, and unpaid work on projects funded by the National Collegiate Athletic Association, and reports honoraria for conference presentations from the National Athletic Trainers’ Association. Dr. DeFreese reports grants from the Atlantic Coast Conference and the Association for Applied Sport Psychology. Dr. Echemendia is a paid consultant for the National Hockey League and co-chair of the National Hockey League/National Hockey League Players Association Concussion Subcommittee and Major League Soccer, and provides testimony in matters related to mTBI. Dr. Guskiewicz reports compensation from the National Collegiate Athletic Association for other services and grants from Boston Children's Hospital (sub-award from the National Football League). Dr. Meehan receives royalties from ABC-Clio Publishing, Springer International, and Wolters Kluwer. His research is funded by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament and a grant from the National Football League. Dr. McCrea reports researching funding for the Medical College of Wisconsin from the National Institutes of Health, Department of Defense, Department of Veterans Affairs, Centers for Disease Control and Prevention, National Football League, National Collegiate Athletic Association, and Abbott Laboratories. He previously served as a consultant to Neurotrauma Sciences, Inc and is a clinical consultant to the Green Bay Packers professional football club. He also reports honoria and travel support for professional speaking engagements. Dr. Mannix reports grants from the U.S. Department of Defense, the NFL Foundation, and the National Institute of Neurological Disorders and Stroke., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: There is a need for evidence-based prevention programming that can reduce head impacts and increase reporting and disclosure of concussion. This study assessed an intervention to decrease concussion risk and improve concussion management through improving concussion-related knowledge, attitudes, intentions, and self-efficacy among parents in the middle school (MS) sport setting., Patients and Methods: This randomized controlled trial (NCT04841473) examined parents of MS-aged children. Participants were randomized into one of two study arms: (1) CDC, which completed an education training module that compiled concussion education from the Centers for Disease Control and Prevention (CDC); and (2) TRAIN + CDC, which completed the CDC training module and an additional TRAIN educational module that provided strategies (originating from the Popular Opinion Leader framework) on communicating such information with one's personal peer networks and children. Validated measures of concussion-related knowledge, attitudes, intentions, and self-efficacy were collected before completing the training modules and one week following completion. Linear mixed model analyses examined differences in outcomes between study arms., Results: Overall, 103 parents completed the training modules and had valid pre- and post-intervention data (TRAIN + CDC n  = 49; CDC n  = 54). Analyses found that the study arms did not differ in the change scores from pre- to post-intervention across concussion-related outcomes. However, scores from pre- to post-intervention improved across both study arms for knowledge metrics, such as 'Concussions are less likely to happen when athletes play by the rules of the sport' ( p  < 0.001), and self-efficacy metrics, such as feeling confident in one's knowledge and recognition of concussion symptoms ( p  < 0.001 and p  = 0.001, respectively)., Conclusions: Although study arms did not differ in change scores from pre- to post-intervention, beneficial increases were nonetheless found across both knowledge and self-efficacy. Additional research is needed to further examine the beneficial manners in which concussion education can be best delivered and the most effective.

Introduction: Sport and tactical populations are often impacted by musculoskeletal injury. Many publications have highlighted that risk is correlated with multiple variables. There do not appear to be existing studies that have evaluated a predetermined combination of risk factors that provide a pragmatic model for application in tactical and/or sports settings., Purpose: To develop and test the predictive capability of multivariable risk models of lower extremity musculoskeletal injury during cadet basic training at the U.S.Military Academy., Materials and Methods: Cadets from the class of 2022 served as the study population. Sex and injury history were collected by questionnaire. Body Mass Index (BMI) and aerobic fitness were calculated during testing in the first week of training. Movement screening was performed using the Landing Error Scoring System during week 1 and cadence was collected using an accelerometer worn throughout initial training. Kaplan-Meier survival curves estimated group differences in time to the first musculoskeletal injury during training. Cox regression was used to estimate hazard ratios (HRs) and Akaike Information Criterion (AIC) was used to compare model fit., Results: Cox modeling using HRs indicated that the following variables were associated with injury risk : Sex, history of injury, Landing Error Scoring System Score Category, and Physical Fitness Test (PT) Run Score. When controlling for sex and history of injury, amodel including aerobic fitness and BMI outperformed the model including movement screening risk and cadence (AIC: 1068.56 vs. 1074.11) and a model containing all variables that were significant in the univariable analysis was the most precise (AIC: 1063.68)., Conclusions: In addition to variables typically collected in this tactical setting (Injury History, BMI, and aerobic fitness), the inclusion of kinematic testing appears to enhance the precision of the risk identification model and will likely continue to be included in screening cadets at greater risk., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: Early medical attention after concussion may minimize symptom duration and burden; however, many concussions are undiagnosed or have a delay in diagnosis after injury. Many concussion symptoms (eg, headache, dizziness) are not visible, meaning that early identification is often contingent on individuals reporting their injury to medical staff. A fundamental understanding of the types and levels of factors that explain when concussions are reported can help identify promising directions for intervention., Purpose: To identify individual and institutional factors that predict immediate (vs delayed) injury reporting., Study Design: Case-control study; Level of evidence, 3., Methods: This study was a secondary analysis of data from the Concussion Assessment, Research and Education (CARE) Consortium study. The sample included 3213 collegiate athletes and military service academy cadets who were diagnosed with a concussion during the study period. Participants were from 27 civilian institutions and 3 military institutions in the United States. Machine learning techniques were used to build models predicting who would report an injury immediately after a concussive event (measured by an athletic trainer denoting the injury as being reported "immediately" or "at a delay"), including both individual athlete/cadet and institutional characteristics., Results: In the sample as a whole, combining individual factors enabled prediction of reporting immediacy, with mean accuracies between 55.8% and 62.6%, depending on classifier type and sample subset; adding institutional factors improved reporting prediction accuracies by 1 to 6 percentage points. At the individual level, injury-related altered mental status and loss of consciousness were most predictive of immediate reporting, which may be the result of observable signs leading to the injury report being externally mediated. At the institutional level, important attributes included athletic department annual revenue and ratio of athletes to athletic trainers., Conclusion: Further study is needed on the pathways through which institutional decisions about resource allocation, including decisions about sports medicine staffing, may contribute to reporting immediacy. More broadly, the relatively low accuracy of the machine learning models tested suggests the importance of continued expansion in how reporting is understood and facilitated., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This work was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the DoD through the Psychological Health and Traumatic Brain Injury Research Program under award No. W81XWH-20-2-0044. This publication was also made possible with support from the Grand Alliance Concussion Assessment, Research and Education (CARE) Consortium, funded in part by the National Collegiate Athletic Association (NCAA) and DoD. The US Army Medical Research Acquisition Activity is the awarding and administering acquisition office. E.K-H. has received consulting fees from the NCAA. J.K.R-M. has consulted for Allied Health Education (paid) and has received speaker honoraria and travel reimbursements for talks given. She served previously (unpaid) on USA Football’s Football Development Council. R.C.L. has received current or past funding from the National Operating Committee on Standards for Athletic Equipment and the National Football League (NFL). S.P.B. has received current or past research funding from NFL/Under Armour/GE, Simbex, and ElMindA; has consulted for US Soccer (paid), US Cycling (unpaid), the University of Calgary SHRed Concussions external advisory board (unpaid), and medicolegal litigation; and has received speaker honoraria and travel reimbursements for talks given. He is coauthor of Biomechanics of Injury (3rd ed) and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (US application No. 17/164,490). M.A.M. has current or past research funding from NFL and Abbott Laboratories. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Sport-related concussion (SRC) is a prevalent injury. Significant disparities in SRC outcomes exist across racial and ethnic groups. These disparities may be attributed to the unequal distribution of political power (or influence) and resource allocation in various communities, shaping individuals' social determinants of health (SDOH). However, the influence of SDOH on SRC outcomes remains understudied. In this clinical commentary, we use the National Institute on Minority Health and Health Disparities Research Framework and describe how its application can help address gaps in our understanding of SDOH and SRC. This framework provides a comprehensive approach to investigating and addressing health disparities by considering SDOH along multiple levels and domains of influence. Using this framework, athletic trainers can identify areas requiring intervention and better understand how SDOH influence SRC outcomes. This understanding can help athletic trainers develop tailored interventions to promote equitable care for patients with SRC., (© by the National Athletic Trainers' Association, Inc.)

Context: Middle school (MS) parents may benefit from education supporting timely concussion identification and care-seeking in their young children (aged approximately 10 to 15 years). However, such education may not consider individual needs and different social context factors, including lower socioeconomic status, disadvantaged social determinants of health, and different racial and ethnic backgrounds., Objectives: To examine the relationship between social context factors and concussion knowledge, attitudes, and communication in MS parents and to explore the possible role of race and ethnicity (Black or White) as an effect measure modifier., Design: Cross-sectional study., Setting: Online survey., Patients or Other Participants: A nationally representative sample of MS parents who completed an online survey (n = 1248)., Main Outcome Measure(s): Parent outcomes were a history of concussion education, concussion symptom knowledge and attitudes, and communication with children about concussion. Main exposures were parental race and ethnicity (Black or White) and social context factors. Uni- and multivariable statistical analyses were performed to achieve the study aims., Results: Black parents were more likely than White parents to have received concussion education (69.5% versus 60.5%, P = .009), although median concussion knowledge scores were higher for White parents than for Black parents (40 versus 37, P < .001). Few associations were found for social context factors with concussion knowledge, attitudes, and communication in Black and White parents separately., Conclusions: Among MS parents, race and ethnicity may not influence the association between social context factors and concussion-related knowledge, attitudes, or communication. However, differences were present by race and ethnicity regarding previous concussion education and other parental outcomes, concussion symptom knowledge in particular., (© by the National Athletic Trainers’ Association, Inc.)

Updated recommendations on preseason heat safety in high school (HS) athletics ("2021 Consensus Statements") were published in April 2021. This cross-sectional survey study explored the initial roll-out of the 2021 Consensus Statements, including their visibility among United States HS athletic trainers (ATs) and perceived levels of confidence in implementing them. Recruitment occurred first, from a random selection of ATs from the Board of Certification, Inc., and second, an open invitation via social media. An online cross-sectional questionnaire had participating ATs note whether they had seen the 2021 Consensus Statements. If yes, ATs reported their perceived level of confidence in implementing them (5-point-ordinal scale from "not at all confident" to "very confident); if no, ATs disclosed (open-ended) why they had not yet seen them. Descriptive statistics were calculated for quantitative variables; template analysis identified codes related to visibility of and confidence in implementing 2021 Consensus Statements. Nearly half (45.7%) of 116 responding HS ATs reported having seen at least one 2021 Consensus Statements; 23.3% had reviewed all three. Common reasons among the 63 that had not seen them included: not aware they were published (n = 22), have yet to read them (n = 19), and believed they could not access the journal (n = 10). Of the 53 ATs having seen at least one of the 2021 Consensus Statements, 67.9% (n = 36) were very/fairly confident in implementing them at their HS. Reasons for confidence included their schools ensuring up-to-date EHI prevention and management practices (n = 18) and athletics constituent support (n = 8). This exploratory study observed proportions of surveyed HS ATs that had not seen the 2021 Consensus Statements and were not confident in implementing them. Findings highlight the need to continue improving messaging about access to best-practice recommendations. Further, continued efforts inclusive of active and passive dissemination strategies across all athletics constituents are needed to aid proper implementation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Kerr et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Timely and appropriate medical care after concussion presents a difficult public health problem. Concussion identification and treatment rely heavily on self-report, but more than half of concussions go unreported or are reported after a delay. If incomplete self-report increases exposure to harm, blood biomarkers may objectively indicate this neurobiological dysfunction., Purpose/hypothesis: The purpose of this study was to compare postconcussion biomarker levels between individuals with different previous concussion diagnosis statuses and care-seeking statuses. It was hypothesized that individuals with undiagnosed concussions and poorer care seeking would show altered biomarker profiles., Study Design: Cohort study; Level of evidence, 3., Methods: Blood samples were collected from 287 military academy cadets and collegiate athletes diagnosed with concussion in the Advanced Research Core of the Concussion Assessment, Research and Education Consortium. The authors extracted each participant's self-reported previous concussion diagnosis status (no history, all diagnosed, ≥1 undiagnosed) and whether they had delayed or immediate symptom onset, symptom reporting, and removal from activity after the incident concussion. The authors compared the following blood biomarkers associated with neural injury between previous concussion diagnosis status groups and care-seeking groups: glial fibrillary acidic protein, ubiquitin c-terminal hydrolase-L1 (UCH-L1), neurofilament light chain (NF-L), and tau protein, captured at baseline, 24 to 48 hours, asymptomatic, and 7 days after unrestricted return to activity using tests of parallel profiles., Results: The undiagnosed previous concussion group (n = 21) had higher levels of NF-L at 24- to 48-hour and asymptomatic time points relative to all diagnosed (n = 72) or no previous concussion (n = 194) groups. For those with delayed removal from activity (n = 127), UCH-L1 was lower at 7 days after return to activity than that for athletes immediately removed from activity (n = 131). No other biomarker differences were observed., Conclusion: Individuals with previous undiagnosed concussions or delayed removal from activity showed some different biomarker levels after concussion and after clinical recovery, despite a lack of baseline differences. This may indicate that poorer care seeking can create neurobiological differences in the concussed brain., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: All authors received funding from the National Collegiate Athletic Association (NCAA) and/or the Department of Defense (DOD) to complete this investigation and cover travel costs related to the study. This work was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the DOD through the Psychological Health and Traumatic Brain Injury Research Program under award No. W81XWH-20-2-0044. This publication was also made possible with support from the Grand Alliance Concussion Assessment, Research and Education (CARE) Consortium, funded in part by the NCAA and the DOD. The U.S. Army Medical Research Acquisition Activity (820 Chandler Street, Fort Detrick, MD 21702-5014) is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under award No. W81XWH-14-2-0151. J.R.M. and R.C.L. have received research funding from the National Operating Committee for the Standards on Athletic Equipment. S.P.B. has consulted for US Soccer (paid), US Cycling (unpaid), and medicolegal litigation; and received speaker honoraria and travel reimbursements for talks given. He is coauthor of Biomechanics of Injury, 3rd edition, and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (U.S. application No. 17/164,490). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objective: Investigate the relationships between concussion history and years of football participation (repetitive head impact proxy) with alcohol use across multiple decades in former professional football players., Methods: Participants (n = 348; mean age = 49.0 ± 9.4) completed health questionnaires in 2001 and 2019, which included self-reported concussion history and years of participation. Alcohol use frequency and amount per occasion were reported for three timepoints: during professional career, 2001, and 2019. Ordinal logistic regression models were fit to test associations of concussion history and years of participation with alcohol use at each timepoint., Results: There were no significant associations between either concussion history or years of football participation with alcohol use (frequency and amount per occasion) at any timepoint. Effect estimates for concussion history and years of football participation with alcohol use were generally comparable across timepoints., Conclusions: Later life alcohol use by former American football players is not associated with concussion history or years of exposure to football., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Concussions are a common sport-related injury that require appropriate initial care. Athletic trainers, often a primary source of healthcare for student-athletes, are key individuals involved in initial concussion diagnostic and management decisions. Challenges exist within the athletic environment that may hinder the consistency, efficacy, and/or effectiveness of concussion-related decision-making by athletic trainers, thereby impacting secondary concussion prevention and patient health. The purpose of this study was to identify factors that impact the intentions of athletic trainers to make appropriate concussion-related decisions under various circumstances. Overall, 1029 participants completed a survey examining educational precursors (quantity and quality of healthcare communication educational focus), demographic precursors (age, gender, educational degree, and employment setting), theory-based mediators (attitudes, perceived norms, and personal agency), and external mediators (knowledge, salience, and communication/collaboration practices) on appropriate concussion-related decision-making intentions. Data were analyzed using a two-step structural equation modeling approach. Quality of healthcare communication educational focus indirectly impacted appropriate concussion-related decision-making intentions via perceived behavioral control and communication/collaboration practices. Additionally, several factors impacted intentions to make appropriate concussion-related decisions directly including employment setting, self-efficacy, and general attitudes towards decision-making and concussions. Concussion prevention is aided by the initial and appropriate action taken by a healthcare professional to reduce immediate consequences; however, this action may be influenced by stakeholder relationships. These influential factors of decision-making may place athletes at further injury risk and negatively impact overall athlete health. As such, a sound theoretical framework incorporating the complexity of factors that may influence decision-making is needed.

Purpose: Investigate the association between self-reported subjective and performance-based cognition among older (50-70 years) former professional American football players, as well as the relationship of cognitive measures with concussion history and years of football participation, as a proxy for repetitive head impact exposure., Methods: Among older former National Football League (NFL) players ( N = 172; mean age = 60.69 ± 5.64), associations of subjective (Patient Reported Outcome Measurement Information System Cognitive Function-Short Form) and performance-based cognitive measures (Brief Test of Adult Cognition by Telephone [BTACT] Executive Function and Episodic Memory indices) were assessed via univariable and multivariable regression models, with a priori covariates of depression and race. A similar univariate and multivariable regression approach assessed associations between concussion history and years of football participation with subjective and performance-based cognitive measures. In a sample subset ( n = 114), stability of subjective cognitive rating was assessed via partial correlation., Results: Subjective ratings of cognition were significantly associated with performance-based assessment, with moderate effect sizes (episodic memory ηp2 = 0.12; executive function ηp2 = 0.178). These associations were weakened, but remained significant ( P s < 0.05), with the inclusion of covariates. Greater concussion history was associated with lower subjective cognitive function ( ηp2 = 0.114, P < 0.001), but not performance-based cognition. The strength of association between concussion history and subjective cognition was substantially weakened with inclusion of covariates ( ηp2 = 0.057). Years of participation were not associated with measures of subjective or objective cognition ( P s > 0.05)., Conclusions: These findings reinforce the importance of comprehensive evaluation reflecting both subjective and objective measures of cognition, as well as the consideration of patient-specific factors, as part of a comprehensive neurobehavioral and health assessment of older former contact sport athletes., (Copyright © 2023 by the American College of Sports Medicine.)

There is a growing concern around concussions in rugby union, at all levels of the game. These concerns highlight the need to better manage and care for players. However, consistency around concussion-related responsibilities of stakeholders across the community rugby system remains challenging. Taking a systems thinking approach, this pragmatic, qualitative descriptive study explored key stakeholder groups within New Zealand's community rugby system's perceptions of their own and others' concussion-related responsibilities. Participants included players from schools and clubs, coaches, parents, team leads and representatives from four provincial unions. A total of 155 participants (67 females and 88 males) were included in the study. Focus groups and individual interviews were conducted. Thematic content analysis was used to analyse data. Thirty concussion-related responsibilities were identified. These responsibilities were contained within four themes: (1) policies and support (responsibilities which influence policy, infrastructure, human or financial resources); (2) rugby culture and general management (responsibilities impacting players' welfare and safety, attitudes and behaviour, including education, injury reporting and communication); (3) individual capabilities (responsibilities demonstrating knowledge and confidence managing concussion, leadership or role/task shifting) and (4) intervention following a suspected concussion (immediate responsibilities as a consequence of a suspected concussion). The need for role clarity was a prominent finding across themes. Additionally, injury management initiatives should prioritise communication between stakeholders and consider task-shifting opportunities for stakeholders with multiple responsibilities. How concussions will realistically be managed in a real-world sports setting and by whom needs to be clearly defined and accepted by each stakeholder group. A 'framework of responsibilities' may act as a starting point for discussion within different individual community rugby contexts on how these responsibilities translate to their context and how these responsibilities can be approached and assigned among available stakeholders., Competing Interests: Competing interests: During the course of the study, DMS and JC were employed by NZ Rugby., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective This study examined how associations of self-reported concussion history and depression vary based on different variable characterizations. Methods Former NFL players ( n   =   1,697) completed a General Health Survey, indicating the number of concussions they sustained during their football career and whether a physician had diagnosed them with depression, and the PROMIS 4-item Depression scale. Self-reported concussion history was characterized as: a 3-category variable (0, 1-2, 3+) with (1) indicator variables and (2) as an ordinal variable; a 5-category variable (0, 1-2, 3-5, 6-9, 10+) with (3) indicator variables and (4) as an ordinal variable; and (5) the original interval scale (0, 1, 2,…, 10, 10+). Depression was characterized as: (1) physician diagnosis (yes/no); and the PROMIS 4-item Depression scale treated as: (2) the original T -score variable and (3) using a cut-off of a T -score >60 versus ≤60. Regression models with various combinations of the characterizations, while adjusting for age, race/ethnicity, education, pain interference, and stress level, estimated prevalence ratios and mean differences for binary and continuous outcomes, respectively. Concussion history-related effect estimates were compared across all models. Results Self-reported concussion history emerged as a significant predictor of each depression measure. With a higher number of concussions reported, be it via the categories or the interval scale, stronger associations between self-reported concussion history and depression were observed. Conclusions The various approaches to characterize self-reported concussion history and depression provided evidence of significant associations between the two variables, with the degree of association varying based on characterization of each construct.

Objective: Investigate associations between the LIfestyle for BRAin Health (LIBRA) risk score with odds of mild cognitive impairment (MCI) diagnosis and cognitive function, incorporating concussion history., Methods: Former National Football League (NFL) players (N = 1050; mean age = 64.8 ± 9.0-years) completed initial testing for integration of concussion history into LIBRA scores (i.e., modified-LIBRA) and completed the Brief Test of Adult Cognition by Telephone (BTACT). Modified-LIBRA score (including concussion history) associations with odds of MCI and cognitive dysfunction were assessed via logistic and linear regression., Results: The highest quartile LIBRA scores were six times more likely to have a diagnosis of MCI compared to the lowest quartile (OR = 6.27[3.61, 10.91], p < 0.001). Modified-LIBRA scores significantly improved model fit for odds of MCI above original LIBRA scores (χ 2 (1) = 7.76, p = 0.005) and accounted for a greater fraction of variance in executive function (ΔR 2  = 0.02, p = 0.003) and episodic memory (ΔR 2  = 0.02, p = 0.002)., Conclusions: Modified-LIBRA score, incorporating concussion history, may help monitoring risk status in former contact sport athletes, by targeting modifiable, lifestyle-related risk factors., (© 2023 the Alzheimer's Association.)

Objectives: Subjective cognitive difficulties (SCDs) are associated with factors commonly reported in older adults and former contact sport athletes, regardless of objective cognitive decline. We investigated the relative contribution of these factors to SCD in former National Football League (NFL)-players with and without a diagnosis of mild cognitive impairment (MCI)., Methods: Former NFL players (n = 907) aged ≥ 50 years (mean = 64.7 ± 8.9), with (n = 165) and without (n = 742) a diagnosis of MCI completed health questionnaires. Multivariable regression and dominance analyses determined the relative importance of SCD factors on SCD: 1) depression, 2) anxiety, 3) sleep disturbance, 4) pain interference, 5) ability to participate in social roles and activities, 6) stress-related events, 7) fatigue, 8) concussion history, and 9) education. SCD outcomes included Neuro-QoL Emotional-Behavioral Dyscontrol and the PROMIS Cognitive Function. Fisher's z-transformation compared comorbid contributing factors to SCD across MCI and non-MCI groups., Results: Complete dominance of anxiety was established over most comorbid factors across the MCI and non-MCI groups. Fatigue also exhibited complete dominance over most comorbid factors, though its influence in the MCI group was less robust (general dominance). Average contributions to variance accounted for by comorbid factors to ratings of SCD across MCI and non-MCI groups did not statistically differ (Z-statistics <1.96, ps>.05)., Conclusions: Anxiety and fatigue are the most robust factors associated with SCD in former professional football players across various combinations of clinical presentations (different combinations of comorbid factors), regardless of documented cognitive impairment. Self-reported deficits may be less reliable in detecting objective impairment in the presence of these factors, with multidimensional assessment being ideal.

Context: Individuals with lower extremity osteoarthritis (OA) have a 25% greater risk of cardiovascular disease (CVD) than those without OA. The prevalence of traumatic joint injuries among National Football League (NFL) players exposes these athletes to an elevated risk for OA and potentially a greater risk of cardiovascular risk factors (CRFs) and CVD., Objectives: To examine the associations between a history of lower extremity joint injury, lower extremity OA, and the prevalence of CRFs and CVD among former NFL athletes., Design: Cross-sectional study., Patients or Other Participants: Former NFL players completed a comprehensive health questionnaire that was used in an ongoing study, the Neurologic Function Across the Lifespan: A Prospective, Longitudinal, and Translational Study for Former NFL Players (NFL-LONG). A subsample of 1738 former players reported lifetime medical diagnoses including CVD or CRFs., Main Outcome Measure(s): Crude and adjusted prevalence ratios (PRsadj) characterized the associations between CVD or CRFs and injury, OA diagnosis, or both among athletes who reported (1) no history of lower extremity joint injury or surgery and no diagnosed OA, (2) a history of lower extremity joint injury or surgery and no diagnosed OA, and (3) a history of lower extremity joint injury or surgery and diagnosed OA., Results: Neither a history of lower extremity joint injury (PRadj = 1.34; 95% CI = 0.86, 2.07) nor a history of lower extremity joint injury and diagnosed OA (PRadj = 1.41; 95% CI = 0.89, 2.25) was significantly associated with CVD. However, CRFs were 30% and 53% more prevalent in former players with lower extremity joint injury and no diagnosed OA (PRadj = 1.30; 95% CI = 1.12, 1.50) and those with lower extremity joint injury and diagnosed OA (PRadj = 1.53; 95% CI = 1.31, 1.78), respectively, versus athletes with no history of either condition., Conclusions: The prevalence of CRFs was highest among former NFL athletes with a history of lower extremity joint injury and diagnosed OA. These findings provide insight regarding the potential pathways to chronic diseases that may be initiated by joint injury early in life., (© by the National Athletic Trainers’ Association, Inc.)

Background: The age of first exposure (AFE) to American football participation is a growing concern for late-life function. Mixed evidence exists surrounding AFE and may be attributed to varied methods employed across studies., Objective: To examine the associations between AFE to American football participation with measures of cognitive, behavioral, and physical function and brain-related medical diagnoses across age categories among former National Football League players., Methods: We conducted a cross-sectional survey of 1784 former players (age: 52.3 ± 16.3 years, AFE: 11.3 ± 2.9 years, years of football: 17.5 ± 4.5 years, 86.9% ≥ one lifetime concussion). Players completed a general health questionnaire recording demographics, football playing history (including AFE), and diagnoses (anxiety, depression, any form of dementia, mild cognitive impairment). Players completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures assessing domains of cognitive and physical function, anxiety, depression, sleep disturbance, pain interference, and emotional-behavioral dyscontrol. Multivariable linear and binomial regression models were used to examine the associations of AFE and age with PROMIS outcomes and diagnoses, respectively., Results: No significant AFE by age interactions were detected for PROMIS outcomes (p ≥ 0.066) or diagnoses (p ≥ 0.147). Younger AFE associated with higher PROMIS scores of anxiety (B = - 0.22, p = 0.016), depression (B = - 0.22, p = 0.010), sleep disturbances (B = - 0.16, p = 0.007), pain interference (B = - 0.19, p = 0.014), and emotional-behavioral dyscontrol (B = - 0.22, p = 0.019). Age was associated with all PROMIS outcomes (p ≤ 0.042). AFE was not associated with the prevalence of anxiety, depression, dementia, or mild cognitive impairment (p ≥ 0.449), while age was (p ≤ 0.013)., Conclusions: AFE was significantly associated with PROMIS outcomes, albeit low-strength associations (i.e., effect sizes), but not with diagnoses. Our findings indicate AFE is a significant but minor contributing factor for health-related quality of life in this cohort. Future work should incorporate additional characterizations of cumulative head impacts and related factors when examining long-term outcomes associated with football participation., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Context: Having athletic trainers (ATs) employed at secondary schools is associated with improved preparedness for sport-related emergencies. The use of emergency medical services (EMS) in settings with different access to athletic training services remains unknown., Objective: To compare the incidence of EMS activations for patients with sport-related injuries among zip codes with various levels of access to athletic training services., Design: Descriptive epidemiology study., Setting: Data were obtained from the National EMS Information System and the Athletic Training Location and Services Project., Patients or Other Participants: Zip codes where 911 EMS activations for sport-related injuries among individuals 13 to 18 years old occurred., Main Outcome Measure(s): Incidence of EMS activations, athletic training service level (no ATs employed [NONE], less than full-time employment [PARTIAL], all ATs employed full time [FULL]), and athletic training employment model (independent contractor [IC], medical or university facility [MUF], school district [SD], mixed employment models [MIX]) for each zip code., Results: The EMS activations were 2.8 ± 3.6 per zip code (range = 1-81, N = 4923). Among zip codes in which at least 1 AT was employed (n = 2228), 3.73% (n = 83) were IC, 38.20% (n = 851) were MUF, 27.24% (n = 607) were SD, and 30.83% (n = 687) were MIX. Compared with SD, MUF had a 10.8% lower incidence of EMS activations (incidence rate ratio [IRR] = 0.892; 95% CI = 0.817, 0.974; P = .010). The IC (IRR = 0.920; 95% CI = 0.758, 1.118; P = .403) and MIX (IRR = 0.996; 95% CI = 0.909, 1.091; P = .932) employment models were not different from the SD model. Service level was calculated for 3834 zip codes, with 19.5% (n = 746) NONE, 46.2% (n = 1771) PARTIAL, and 34.4% (n = 1317) FULL. Compared with NONE, FULL (IRR = 1.416; 95% CI = 1.308, 1.532; P < .001) and PARTIAL (IRR = 1.368; 95% CI = 1.268, 1.476; P < .001) had higher incidences of EMS activations., Conclusions: Local access to athletic training services was associated with an increased use of EMS for sport-related injuries among secondary school-aged individuals, possibly indicating improved identification and triage of sport-related emergencies in the area. The difference in EMS use among employment models may reflect different policies and procedures for sport-related emergencies., (© by the National Athletic Trainers' Association, Inc.)

Background: Participation in sports is associated with many benefits to all aspects of health; however, it also comes with the risk of injury, particularly concussions. Self-disclosure and care seeking following a concussion are especially important because of the lack of outwardly visible signs and/or symptoms. Although recent research has explored factors affecting concussion disclosure, use of isolated methodologies limits the ability to contextualize how disclosure or nondisclosure occurs. Therefore, the purpose of this study was to describe the factors and expectations of National Collegiate Athletic Association (NCAA) athletes that may influence concussion disclosure., Methods: This mixed-methods convergent parallel research study included 25 NCAA Division I athletes representing 13 sports, all of whom completed a concussion-education session with pre-/post-test surveys and a semistructured interview. Eligible athletes were at least 18 years old and on an NCAA roster. The surveys focused on previous concussion-related disclosure behaviors, knowledge, attitudes, beliefs, norms, and intentions about disclosing concussion. Interviews focused on the athletes' experiences related to concussion disclosure. Survey data were analyzed using descriptive statistics and Mann-Whitney U tests. Interviews were analyzed using a Consensual Qualitative Research tradition., Results: Participants had good concussion knowledge (median = 46.0), positive attitudes (median = 38.0), strong beliefs (median = 13.0), and strong intentions to disclose concussion symptoms (median = 7.0). None of the constructs differed by participants' gender. Although quantitative findings were mostly positive, interview data highlighted factors that may explain why some participants are successful in disclosing concussions and why others may find disclosure difficult. Educational efforts, sport culture, and medical professional presence were the primary facilitators discussed by participants. Stigma, pressure, and a lack of team support were perceived as disclosure barriers., Conclusion: The context in which concussion disclosure occurs or does not occur is vital to the success of educational interventions. Interventions must prioritize stakeholder- and team-based perspectives on concussion to establish a network supportive to disclosure., (Copyright © 2021. Production and hosting by Elsevier B.V.)

Objective: Studies have observed variable associations of prior contact sport participation with subjective and objective measures of cognitive function. This study directly investigated the association between subjective self-report and objective performance-based cognition among former collegiate football players, as well as its relationship to self-reported concussion history., Methods: Former collegiate football players (N = 57; mean age = 37.9 years [ SD  = 1.49]) retired from sport 15-years prior were enrolled. Linear regression models examined associations between subjective cognition (Quality of Life in Neurological Disorders Cognitive Functioning-Short Form), and performance on a neuropsychological battery. Domain specific (executive function) metrics of subjective (Behavior Rating Inventory of Executive Function-Adult) and objective cognition were also exclusively examined. Associations between self-reported concussion history with subjective and objective measures were tested. Potential influential factors (sleep quality and distress) were included as covariates., Results: Subjective cognition was not significantly associated with any objective measures of cognitive functioning ( p 's > .05). Greater self-reported concussion history was inversely associated with subjective cognition (B = -2.49, p = .004), but not objective performance-based cognition ( p 's > .05). Distress was significantly related to all metrics of subjective cognition ( p 's < .001) as well as performance on delayed recall and verbal fluency ( p 's < .05). Sleep quality was only significantly related to timed visuospatial sequencing ( p = .033)., Conclusions: Reliance on self-reported measures of cognitive functioning alone is insufficient when assessing cognition in former contact sport athletes. Assessment of other factors known to influence subjective cognitive complaints should also be examined in determining the presence of cognitive deficits.

Middle school (MS) is an intermediary level of education between elementary and secondary school that typically includes students aged 10-15 years. There is limited research within the MS sport setting, particularly related to sport-related injury prevention. This qualitative study aimed to better understand the sport culture within MS sports and the communication strategies used among invested groups (i.e., athletes, parents, staff inclusive of coaches and school nurses). Semi-structured interviews were conducted with 19 athletes, 20 parents, and 18 staff (e.g., coaches, school nurses) from seven MS in two school districts during the 2018/19 and 2019/20 school years. Topics focused on understanding school- and sport-related factors related to education, safety, and communication. Analysis used a consensual qualitative research tradition, in which the research team discussed individually developed themes and categories from transcribed interviews, with the goal of coming to a consensus and creating a codebook. Throughout the coding process, the research team would reconvene to discuss coding decisions until consensus was reached. This study focuses on the themes of sport culture and communication. Dominant categories identified within sport culture related to participants noting why they were interested in MS sports, and their struggles with their perceived roles and engagement (e.g., helping parents stay engaged, finding coaches, oversight of school nurses). Competitiveness and safety could have conflicting roles and priority. Dominant categories identified within communication centered around limited communication between coaches and parents. Technological assistance (e.g., phone apps, websites) was available, but often varied by school and sport. Concussions were seldom discussed unless during the preseason meeting or when one occurred. Findings highlight that the MS sport settings may struggle with incorporating primary prevention into their cultures and ensuring reliable communication among individuals. Novel and tailored approaches to injury prevention are needed to help ensure buy-in and proper implementation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Kerr et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Relationships between the constructs of concussion-related knowledge, attitudes, and norms and their influence on observed care-seeking behaviors have previously been examined. Current models posit that these constructs serve as potential mediators of care-seeking behaviors; however, the dynamics between them have yet to be reconciled., Methods: A cross-sectional, online survey explored relationships among the latent constructs of concussion-related knowledge, attitudes, and norms in parents of middle school children who participate in sports in multiple settings. A just-identified and two overidentified path models were explored and compared in an effort to understand such relationships., Results: A total of 426 parents of United States middle school students were surveyed and included in analyses (mean age = 38.7±9.9 years; 55.6% female; 51.4% white/non-Hispanic; 56.1% with at least a bachelor's degree). All parents had middle school aged children who participated in sport in both the club and school settings. The best fitting model was a just-identified model with concussion-related norms influencing concussion-related knowledge and attitudes, and concussion-related knowledge influencing attitudes. This model accounted for 14% of the variance in attitude and 12% of the variance in knowledge., Conclusions: Study findings suggest that the constructs of concussion-related knowledge, attitudes and norms are directly related to one another, yet the dynamics of such relationships may be complex. As such, a parsimonious interpretation of these constructs may not be appropriate. Future research should work to further reconcile the dynamics between these constructs, and the impact these dynamics may have in influencing care-seeking behaviors beyond serving as mediators., Competing Interests: Dr. Aliza Nedimyer, PhD, LAT, ATC has received research funding from the National Athletic Trainers’ Association Research and Education Foundation for an unrelated project Dr. Johna K. Register-Mihalik, PhD, LAT, ATC, FACSM, FNATA has received research funding to her institution from the Centers for Disease Control and Prevention, Department of Defense, National Operating Committee on Standards from Athletic Equipment, NATA Foundation, National Football League, and NCAA-DOD Mind Matters Research Challenge. Further, Dr. Register-Mihalik previously served on USA Football’s Football Development Council and currently serves on the Girls Football Advisory Council. Dr. Avinash Chandran, PhD, MS is the Director of the NCAA Injury Surveillance Program at the Datalys Center for Sports Injury Research and Prevention. He discloses funding from the NCAA as Director of the NCAA Injury Surveillance Program. He also discloses funding the NC Translational and Clinical Sciences Institute, the ACC Center for Research in Intercollegiate Athletics, as well as the Canadian Institutes of Health Research- Human Development, Child and Youth Health Institute, on separate, unrelated projects. No other authors have conflicts of interest to report. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Nedimyer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Laborers are particularly vulnerable to exertional injuries and illnesses, as they often engage in heavy physical work for prolonged hours, yet no studies have examined the top causes of catastrophic exertional injuries and fatalities among this population. The purpose of the investigation was to characterize the top causes of exertional injury and fatality within open access, Occupational Safety and Health Administration (OSHA) reportable data. A secondary analysis of OSHA reported injury and fatality data was performed through open access records from OSHA Severe Injury Reports (2015-2022) and OSHA fatality inspection data (2017-2020), respectively. The research team characterized each reported injury and fatality as "exertion-related" or "non-exertion-related. Injury and fatality rates were reported per 100,000 equivalent full-time worker years and included 95% confidence intervals (95% CI). Of 58,648 cases in the OSHA Severe Injury Report database from 2015-2020, 1682 cases (2.9%) were characterized as exertional (0.20 injuries per 100,000 full-time worker years, 95% CI: 0.19, 0.22). Heat-related injuries encompassed 91.9% of the exertional injuries ( n = 1546). From the 2017-2022 OSHA fatality inspection database, 89 (1.9%) of 4598 fatalities were characterized as exertion-related (fatality rate: 0.0160 per 100,000 full-time equivalent workers, 95% CI: 0.009, 0.0134). The exertion-related fatalities primarily consisted of heat-related cases (87.6%). Exertion-related injuries and fatalities were most reported in Southeast states, in the construction and excavation industry, and among nonunionized workers. As heat stress continues to be recognized as an occupational health and safety hazard, this analysis further highlights the need for targeted interventions or further evaluation of the impact of heat stress on construction and excavation workers, nonunionized workers, and workers in Southeastern states.

Background: An association has been identified between concussion and lower extremity musculoskeletal injury (LEMSKI) after return to sports participation. However, the collegiate student-athlete studies have relied on relatively small single-institution studies, which limits generalizability., Purpose: To assess odds of, and time to, LEMSKI after concussion in US collegiate athletes, using the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP)., Study Design: Descriptive epidemiology study., Methods: Data from the NCAA ISP during the 2010-2011 through 2019-2020 athletic seasons were considered for analysis. Frequency distributions were examined for details related to the initial and subsequent injuries (injuries to bone, bursa, joint, ligament, muscle, or tendon). Multivariable logistic regression models and random-effects Poisson regression models examined odds of time loss (TL) and non-time loss (NTL) LEMSKI after concussion, as well as the time interval between initial concussion and subsequent LEMSKI in a single athletic season, or initial musculoskeletal injury (MSKI) and subsequent LEMSKI in a single athletic season. Analyses were performed separately for football and other sports., Results: A total of 31,556 initial injuries were recorded (football: 11,900; other sports: 19,656), which were followed by 0 or 1 injury in the same season. Overall, first injury type was not a significant predictor of subsequent LEMSKI, although certain contrasts yielded significant estimates. In football, the odds of NTL LEMSKI were higher after concussion than after upper extremity MSKI (UEMSKI; adjusted odds ratio [OR Adj ], 1.56; 95% CI, 1.06-2.31). In football, the odds of TL LEMSKI were lower after concussion than after UEMSKI (OR Adj , 0.71; 95% CI, 0.51-0.99). No other significant effect estimates were observed for football or other sports., Conclusion: First injury type, either concussion or upper extremity, was not associated with an elevated risk of LEMSKI. Specifically, the results of this study did not identify an elevated odds of LEMSKI after a concussion. However, the authors observed greater odds of NTL LEMSKI and lower odds of TL LEMSKI in football.

Background: Approximately half of concussions go undisclosed and therefore undiagnosed. Among diagnosed concussions, 51% to 64% receive delayed medical care. Understanding the influence of undiagnosed concussions and delayed medical care would inform medical and education practices., Purpose: To compare postconcussion longitudinal clinical outcomes among (1) individuals with no concussion history, all previous concussions diagnosed, and ≥1 previous concussion undiagnosed, as well as (2) those who have delayed versus immediate symptom onset, symptom reporting, and removal from activity after concussion., Study Design: Cohort study; Level of evidence, 2., Methods: Participants included 2758 military academy cadets and intercollegiate athletes diagnosed with concussion in the CARE Consortium. We determined (1) each participant's previous concussion diagnosis status self-reported at baseline (no history, all diagnosed, ≥1 undiagnosed) and (2) whether the participant had delayed or immediate symptom onset, symptom reporting, and removal from activity. We compared symptom severities, cognition, balance, and recovery duration at baseline, 24 to 48 hours, date of asymptomatic status, and date of unrestricted return to activity using tests of parallel profiles., Results: The ≥1 undiagnosed concussion group had higher baseline symptom burdens ( P < .001) than the other 2 groups and poorer baseline verbal memory performance ( P = .001) than the all diagnosed group; however, they became asymptomatic and returned to activity sooner than those with no history. Cadets/athletes who delayed symptom reporting had higher symptom burdens 24 to 48 hours after injury (mean ± SE; delayed, 28.8 ± 0.8; immediate, 20.6 ± 0.7), took a median difference of 2 days longer to become asymptomatic, and took 3 days longer to return to activity than those who had immediate symptom reporting. For every 30 minutes of continued participation after injury, days to asymptomatic status increased 8.1% (95% CI, 0.3%-16.4%)., Conclusion: Clinicians should expect that cadets/athletes who delay reporting concussion symptoms will have acutely higher symptom burdens and take 2 days longer to become asymptomatic. Educational messaging should emphasize the clinical benefits of seeking immediate care for concussion-like symptoms.

Background: Epidemiological studies of lateral ankle sprains in NCAA sports are important in appraising the burden of this injury and informing prevention efforts., Purpose: To describe the epidemiology of lateral ankle sprains in NCAA sports during the 2014-15 through 2018-19 seasons., Study Design: Descriptive epidemiology study., Methods: Injury and exposure information collected within the NCAA Injury Surveillance Program (ISP) were examined. Counts, rates, and proportions of lateral ankle sprains were used to describe injury incidence by sport, event type (practices, competitions), season segment (preseason, regular season, postseason), injury mechanism (player contact, noncontact, and surface contact, injury history (new, recurrent), and time loss (time loss [≥1 day], non-time loss). Injury rate ratios (IRRs) were used to examine differential injury rates, and injury proportion ratios (IPRs) were used to examine differential distributions., Results: A total of 3910 lateral ankle sprains were reported (4.61 per 10,000 athlete exposures) during the study period, and the overall rate was highest in men's basketball (11.82 per 10,000 athlete exposures). The competition-related injury rate was higher than the practice-related rate (IRR, 3.24; 95% CI, 3.04-3.45), and across season segments, the overall rate was highest in preseason (4.99 per 10,000 athlete exposures). Lateral ankle sprains were most often attributed to player-contact mechanisms in men's (43.2%) and women's sports (35.1%), although injuries were more prevalently attributed to player contact in men's than in women's sports (IPR, 1.23; 95% CI, 1.13-1.34). Overall, 49.7% of all lateral ankle sprains were time loss injuries., Conclusions: The findings of this study are consistent with previous epidemiological investigations of lateral ankle sprains among NCAA athletes. Results offer additional context on differential injury mechanisms between men's and women's sports and on injury risk across the competitive season. Future research may examine the effectiveness of deploying injury prevention programs before the start of a season.

Purpose: There is limited understanding of factors affecting concussion diagnosis status using large sample sizes. The study objective was to identify factors that can accurately classify previous concussion diagnosis status among collegiate student-athletes and service academy cadets with concussion history., Methods: This retrospective study used support vector machine, Gaussian Naïve Bayes, and decision tree machine learning techniques to identify individual (e.g., sex) and institutional (e.g., academic caliber) factors that accurately classify previous concussion diagnosis status (all diagnosed vs 1+ undiagnosed) among Concussion Assessment, Research, and Education Consortium participants with concussion histories ( n = 7714)., Results: Across all classifiers, the factors examined enable >50% classification between previous diagnosed and undiagnosed concussion histories. However, across 20-fold cross validation, ROC-AUC accuracy averaged between 56% and 65% using all factors. Similar performance is achieved considering individual risk factors alone. By contrast, classifications with institutional risk factors typically did not distinguish between those with all concussions diagnosed versus 1+ undiagnosed; average performances using only institutional risk factors were almost always <58%, including confidence intervals for many groups <50%. Participants with more extensive concussion histories were more commonly classified as having one or more of those previous concussions undiagnosed., Conclusions: Although the current study provides preliminary evidence about factors to help classify concussion diagnosis status, more work is needed given the tested models' accuracy. Future work should include a broader set of theoretically indicated factors, at levels ranging from individual behavioral determinants to features of the setting in which the individual was injured., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

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

Background: Exercise has been shown to reduce fatigue in early breast cancer survivors (EBCS), though it is unclear if these results translate to community-based exercise settings. Mechanisms that influence changes in fatigue seen after exercise are also poorly understood. This study sought to evaluate the impact of community-based exercise and identify associations of fatigue in EBCS., Methods: Twenty-nine EBCS and 13 non-cancer controls (CON) enrolled. Pre/post-intervention measurements included measures of fitness/function, balance, and adherence/compliance as well as self-reported measures of fatigue, health-related quality of life (HRQOL), well-being, self-efficacy, and physical activity. Both groups participated in a supervised 16-week aerobic + resistance exercise intervention. A mixed model ANOVA and Cohen's D effect size assessed fatigue changes, and univariable linear regressions identified fatigue associations., Results: Fatigue improved for EBCS (- 2.6, Cohen's D = 0.51) but not CON (0.0, Cohen's D = 0.02); no interaction effect was observed. Post-intervention fatigue in EBCS was associated with better QOL (R 2  = 0.387; p < 0.01), depression (R 2  = 0.251; p < 0.01), self-efficacy, (R 2  = 0.453; p < 0.01), outcome expectations from exercise (R 2  = 0.254; p < 0.01), balance (R 2  = 0.167; p < 0.05), and the 6-minute walk test (R 2  = 0.193; p < 0.05). EBCS improvements in fatigue were associated with improvements in self-reported physical health (R 2  = 0.425; p < 0.01), depression (R 2  = 0.233; p < 0.01), pain (R 2  = 0.157; p < 0.05), outcome expectations from exercise (R 2  = 0.420; p < 0.01), and the 6-minute walk test (R 2  = 0.172; p < 0.05). Less fatigue in the CON group was shown be associated with better sleep quality (R 2  = 0.309; p < 0.05) and pain (R 2  = 0.259; p < 0.05)., Conclusion: Community-based exercise appears beneficial for alleviating fatigue in EBCS. These improvements may be driven by parallel improvements in psychosocial outcomes and objectively measured functional outcomes., (© 2022. The Author(s), under exclusive licence to The Japanese Breast Cancer Society.)

Objective: Parents may use various information sources to obtain information about sport-related concussions (SRC). This study examined SRC-related information sources used by parents of United States middle school children (age: 10-15 years)., Methods: A panel of 1083 randomly selected U.S. residents, aged ≥18 years and identifying as parents of middle school children, completed an online questionnaire capturing parental and child characteristics, and utilization and perceived trustworthiness of various sources of SRC-related information. Multivariable logistic regression models identified factors associated with utilizing each source. Adjusted odds ratios (OR) with 95% confidence intervals (95%CIs) excluding 1.00 were deemed significant., Results: Doctors/healthcare providers (49.9%) and other healthcare-related resources (e.g., Centers for Disease Control and Prevention, WebMD) (37.8%) were common SRC-related information sources; 64.0% of parents utilized ≥1 of these sources. Both sources were considered "very" or "extremely" trustworthy for SRC-related information among parents using these sources (doctors/healthcare providers: 89.8%; other healthcare-related resources: 70.9%). A 10-year increase in parental age was associated with higher odds of utilizing doctors/healthcare providers (adjusted odd ratio (OR adjusted ) = 1.09, 95%CI: 1.02-1.16) and other healthcare-related resources (OR adjusted  = 1.11, 95%CI: 1.03-1.19). The odds of utilizing doctors/healthcare providers (OR adjusted  = 0.58, 95%CI: 0.40-0.84) and other healthcare-related resources (OR adjusted  = 0.64, 95%CI: 0.44-0.93) were lower among parents whose middle school children had concussion histories versus the parents of children who did not have concussion histories., Conclusion: One-third of parents did not report using doctors/healthcare providers or other healthcare-related resources for SRC-related information. Factors associated with underutilization of these sources may be targets for future intervention. Continuing education for healthcare providers and educational opportunities for parents should highlight accurate and up-to-date SRC-related information., (Copyright © 2020. Production and hosting by Elsevier B.V.)

Context: Having athletic trainers (ATs) employed at secondary schools is associated with improved preparedness for sport-related emergencies. Utilization of emergency medical services (EMS) with different access to athletic training services remains unknown., Objective: Compare the incidence of EMS activations for sport-related injuries between zip-codes with varying access to athletic training services., Design: Descriptive epidemiology study., Setting: Data were obtained from the National EMS Information System and the Athletic Training Location and Services Project., Patients or Other Participants: Zip-codes where 9-1-1 EMS activations for sport-related injuries among individuals 13-18 years old occurred., Main Outcome Measure(s): Incidence of EMS activations, athletic training service level (NONE, PART, FULL), athletic training employment model (independent contractor, IC; medical or university facility, MUF; school district, SD; mixed employment models, MIX) for each zip-code., Results: There were 2.8±3.5 EMS activations per zip-code (range 1-81, n=4,923). Among zip-codes where at least 1 AT was employed (n=2,228), 3.73% (n=83) were IC, 30.83% (n=687) were MIX, 27.24% (n=607) were SD, and 38.20% (n=851) were MUF. Compared to SD, MUF had a 10.8% lower incidence of EMS activations (95%CI: 0.817, 0.974, p=0.010). IC (IRR: 0.920, 95%CI: 0.758, 1.118, p=0.403) and MIX (IRR: 0.996, 95% CI: 0.909, 1.091, p=0.932) were not significantly different from SD. Service level was calculated for 3,834 zip-codes, with 19.5% (n=746) NONE, 46.2% (n=1,771) PART, and 34.4% (n=1,317) FULL. Compared to NONE, FULL (IRR: 1.416, 95%CI: 1.308, 1.532, p<0.001) and PART (IRR: 1.368, 95%CI: 1.268, 1.476, p<0.001) had higher incidences of EMS activations., Conclusions: Local access to athletic training services is associated with an increased utilization of EMS for sport-related injuries among secondary school aged individuals, potentially indicative of improved identification and triage of sport-related emergencies the area. The difference in EMS utilization between employment models may represent the presence of different policies and procedures for sport-related emergencies.

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

Background: The prevalence of unreported concussions is high, and undiagnosed concussions can lead to worse postconcussion outcomes. It is not clear how those with a history of undiagnosed concussion perform on subsequent standard concussion baseline assessments., Purpose: To determine if previous concussion diagnosis status was associated with outcomes on the standard baseline concussion assessment battery., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Concussion Assessment, Research, and Education (CARE) Consortium participants (N = 29,934) self-reported concussion history with diagnosis status and completed standard baseline concussion assessments, including assessments for symptoms, mental status, balance, and neurocognition. Multiple linear regression models were used to estimate mean differences and 95% CIs among concussion history groups (no concussion history [n = 23,037; 77.0%], all previous concussions diagnosed [n = 5315; 17.8%], ≥1 previous concussions undiagnosed [n = 1582; 5.3%]) at baseline for all outcomes except symptom severity and Brief Symptom Inventory-18 (BSI-18) score, in which negative binomial models were used to calculate incidence rate ratios (IRRs). All models were adjusted for sex, race, ethnicity, sport contact level, and concussion count. Mean differences with 95% CIs excluding 0.00 and at least a small effect size (≥0.20), and those IRRs with 95% CIs excluding 1.00 and at least a small association (IRR, ≥1.10) were considered significant., Results: The ≥1 previous concussions undiagnosed group reported significantly greater symptom severity scores (IRR, ≥1.38) and BSI-18 (IRR, ≥1.31) scores relative to the no concussion history and all previous concussions diagnosed groups. The ≥1 previous concussions undiagnosed group performed significantly worse on 6 neurocognitive assessments while performing better on only 2 compared with the no concussion history and all previous concussions diagnosed groups. There were no between-group differences on mental status or balance assessments., Conclusion: An undiagnosed concussion history was associated with worse clinical indicators at future baseline assessments. Individuals reporting ≥1 previous undiagnosed concussions exhibited worse baseline clinical indicators. This may suggest that concussion-related harm may be exacerbated when injuries are not diagnosed.

Background: Racial and ethnic differences in emergency department (ED) visits have been reported among adolescent patients but are unsubstantiated among adults. Therefore, our purpose in this study was to examine the relationship between race/ethnicity and adult ED visits for concussions, their injury mechanisms, and computed tomography (CT) scan use among a nationally representative sample., Methods: We used the National Hospital Ambulatory Medical Care Survey database from 2010-2015 to examine 63,725 adult (20-45 years old) patient visits, representing an estimated 310.6 million visits presented to EDs. Of these visits, 884 (4.5 million national estimate) were diagnosed with a concussion. Visit records detailed patient information (age, sex, race/ethnicity, geographic region, primary payment type), ED visit diagnoses, injury mechanism (sport, motor vehicle, fall, struck by or against, "other"), and head CT scan use. The primary independent variable was race/ethnicity (non-Hispanic Asian, non-Hispanic Black or African American, Hispanic/Latinx, non-Hispanic multiracial or another, and non-Hispanic White). We used multivariable logistic and multinomial regression models with complex survey sampling design weighting to examine the relationship between concussion ED visits, injury mechanisms, and CT scan use separately by race/ethnicity while accounting for covariates., Results: There were no associations between race/ethnicity and concussion diagnosis among adult ED visits after accounting for covariates. Relative to sports-related injuries, non-Hispanic Black or African American patient visits were associated with a motor vehicle (OR = 2.69, 95% CI: 1.06-6.86) and "other" injury mechanism (OR = 4.58, 95% CI: 1.34-15.69) compared to non-Hispanic White patients. Relative to sports-related injuries, non-Hispanic Asian, multiracial, or patients of another race had decreased odds of falls (OR = 0.20, 95% CI: 0.04-0.91) and "other" injuries (OR = 0.09, 95% CI: 0.01-0.55) compared to non-Hispanic White patients. The odds of a CT scan being performed were significantly lower among Hispanic/Latinx patient visits relative to non-Hispanic White patients (OR = 0.52, 95% CI: 0.30-0.91), while no other race/ethnicity comparisons differed., Conclusion: Our findings indicate that the overarching concussion ED visit likelihood may not differ by race/ethnicity in adults, but the underlying mechanism causing the concussion and receiving a CT scan demonstrates considerable differences. Prospective future research is warranted to comprehensively understand and intervene in the complex, multi-level race/ethnicity relationships related to concussion health care to ensure equitable patient treatment., Competing Interests: Author ZK reports current and previous funding from CDC, DoD, NFL, and NIH. Author RM acknowledges support from the National Institute of Neurologic Disorders and Stroke (U01NS096835), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NS115942-01A1), the Department of Defense (W81XWH1920011), and Abbott Pharmaceuticals. Author WM receives royalties from (1) ABC-Clio publishing for the sale of his books, Kids, Sports, and Concussion: A guide for coaches and parents and Concussions; (2) Springer International for the book Head and Neck Injuries in Young Athletes and (3) Wolters Kluwer for working as an author for UpToDate separate from this study. His research was funded, in part, by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament and a grant from the National Football League. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lempke, Kerr, Melvin, Walton, Wallace, Mannix, Meehan and Ward.)

The objective of this study was to examine associations of lifetime concussion history (CHx) and an advanced metric of lifetime repetitive head impact exposure with resting-state functional connectivity (rsFC) across the whole-brain and among large-scale functional networks (Default Mode; Dorsal Attention; and Frontoparietal Control) in former collegiate football players. Individuals who completed at least one year of varsity collegiate football were eligible to participate in this observational cohort study (n = 48; aged 36-41 years; 79.2% white/Caucasian; 12.5±4.4 years of football played; all men). Individuals were excluded if they reported history/suspicion of psychotic disorder with active symptoms, contraindications to participation in study procedures (e.g., MRI safety concern), or inability to travel. Each participant provided concussion and football playing histories. Self-reported concussion history was analyzed in two different ways based on prior research: dichotomous "High" (≥3 concussions; n = 28) versus "Low" (<3 concussions; n = 20); and four ordinal categories (0-1 concussion [n = 19]; 2-4 concussions [n = 8]; 5-7 concussions [n = 9]; and ≥8 concussions [n = 12]). The Head Impact Exposure Estimate (HIEE) was calculated from football playing history captured via structured interview. Resting-state fMRI and T1-weighted MRI were acquired and preprocessed using established pipelines. Next, rsFC was calculated using the Seitzman et al., (2020) 300-ROI functional atlas. Whole-brain, within-network, and between-network rsFC were calculated using all ROIs and network-specific ROIs, respectively. Effects of CHx and HIEE on rsFC values were examined using separate multivariable linear regression models, with a-priori α set to 0.05. We observed no statistically significant associations between rsFC outcomes and either CHx or HIEE (ps ≥ .12). Neither CHx nor HIEE were associated with neural signatures that have been observed in studies of typical and pathological aging. While CHx and repetitive head impacts have been associated with changes in brain health in older former athletes, our preliminary results suggest that associations with rsFC may not be present in early midlife former football players., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: BLB reports grants and support from the National Institute of Neurological Disorders and Stroke and National Institute on Aging under the National Institutes of Health. KMG reports compensation from National Collegiate Athletic Association for other services and grants from Boston Children’s Hospital (sub-award from the National Football League). MAM acknowledges researching funding from the National Institutes of Health, U.S. Department of Defense, Centers for Disease Control and Prevention, National Collegiate Association and National Football League (via subaward from Boston Children’s Hospital). No other conflicts of interest are declared for the remaining authors.

Background Literature examining emergency medical services (EMS) activations for sport-related injuries is limited to the pediatric, high school, and collegiate student-athlete populations, excluding older individuals and recreational athletes. The purpose of this study was to examine EMS activations for sport-related injuries using the National EMS Information System Database from 2017-2018. Methods Data were obtained using the National EMS Information System Database from 2017-2018. EMS activations were limited to 9-1-1 responses for individuals aged 3-99 who sustained a sports-related injury. Independent variables included patient age group: pediatric (<18 years old) vs. adult (≥18 years old). Dependent variables were patient age, gender, and chief complaint anatomic location. Frequencies and proportions were calculated for each variable. Injury proportion ratios (IPRs) with 95% confidence intervals were calculated to compare chief complaint anatomic location by age group. Results There were 71,322 sport-related injuries. Patients were 36.6±22.9 years and most (58.1%, n=41,132) were male. Adults had higher proportions of injuries affecting the abdomen (IPR: 2.05, 95%CI: 1.83, 2.31), chest (IPR: 1.90, 95%CI: 1.75, 2.05), general/global (IPR: 1.54, 95%CI: 1.50, 1.58), and genitalia (IPR: 2.40, 95%CI: 1.39, 4.15), and lower proportions of injuries affecting the back (IPR: 0.55, 95%CI: 0.50, 0.60), lower extremity (IPR: 0.63, 95%CI: 0.60, 0.65), upper extremity (IPR: 0.50, 95%CI: 0.47, 0.53), head (IPR: 0.73, 95%CI: 0.70, 0.77), and neck (IPR: 0.18, 95%CI: 0.16, 0.20) compared to pediatric patients. Conclusion Injuries sustained differed between adult and pediatric patients, indicating sport-related emergencies may change across the lifespan. General/global chief complaints likely indicate sport-related injuries affecting multiple anatomic locations and organ systems. Stakeholders planning large or high-risk athletic events should consider arranging standby or dedicated advanced life support units for their events., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Hirschhorn et al.)

Objectives: To examine the stability of former National Football League (NFL) players' recall of professional football concussion., Methods: Two-hundred-and-nine former NFL players (ceasing football participation before/in 2001) completed surveys in 2001, 2010, and 2019 and reported the number of concussions sustained during their professional careers (0, 1 … 10, >10). Participants were categorized into four 'recall stability' groups, based upon concussion recall [e.g., 'Same' (same number recalled), 'Increased' (more recalled than in prior time point)]. In 2019, participants completed measures of functioning (e.g., PROMIS Cognitive Function, Anxiety, Depression). Fleiss Kappa and generalized linear mixed models (GLMM)-based ordinal measures Kappa assessed stability across time points. 'Recall stability group' functioning scores were compared., Results: Overall, 45.9% recalled more concussions over time; 14.8% reported the same number. Fleiss Kappa and GLMM-based ordinal measures Kappa suggested fair (0.22, 95% CI: 0.26, 0.38) and moderate stability (0.41, 95% CI: 0.35, 0.46), respectively. Higher cognitive functioning (P = 0.002), lower anxiety (P = 0.003), and lower depression (P = 0.007) were observed in the 'Same' vs 'Increased' groups., Conclusions: Despite subtle time-based variations in reporting, professional football concussion history recall was relatively stable. Better cognitive and psychological functioning was associated with greater stability in concussion recall.

Background: This study examined the association between participation in school-based and/or community-based activity and major depressive episodes (MDE) in adolescents using nationally representative data., Methods: This study utilized cross-sectional data from the National Survey of Drug Use and Health from 2015 to 2019. Nine screening questions determined the presence of past-year MDE in adolescents ages 12-17 (n = 67,033). Participants indicated past-year participation in school-based (eg, team sports, cheerleading, choir, band, student government, or clubs) and/or community-based activities (eg, volunteer activities, sports, clubs, or groups). Sociodemographic variables included sex, race/ethnicity, family income, and age. Descriptive statistics, univariable and multivariable regression analyses were conducted. The multivariable model included interaction terms between age and sex, and age and race/ethnicity., Results: Overall, 14% of the sample met the criteria for having MDE. The odds of MDE increased with age. Joint effects of age and sex, and age and race/ethnicity significantly influenced the association between MDE and school- or community-based activities. Participation in 1+ community-based activities was protective for MDE across all races/ethnicities., Conclusions: Findings help illuminate the direct association of school- and community-based activity participation on MDE risk in adolescents, improving our understanding of MDE across various sociodemographic subgroups in an adolescent population. Schools should aim to facilitate equitable programming and endorse adolescent participation in multiple activities throughout the year. Schools should examine the resources available and consider partnerships that would bolster resources, access, and social capital throughout the community., (© 2022 American School Health Association.)

Purpose: Examine baseline fatigue levels in early-breast cancer survivors (EBCS) compared to inactive controls (CON) and identify associated physical and psychosocial factors with fatigue prior to community-based exercise., Methods: A total of 33 EBCS (53.9 ± 11.4 years) and 21 CON (54.0 ± 8.0 years) were recruited. Participants completed questionnaires for demographics and patient-reported outcome measures pertaining to fatigue, quality of life, mental health, and physical activity, and completed a 6-min walk test, balance assessment, cardiopulmonary exercise test (VO 2peak ), and muscular strength test. A Mann-Whitney U test compared fatigue between groups and unadjusted univariable linear regressions were used to explore relationships with fatigue., Results: Fatigue in EBCS was not statistically different from CON (EBCS: 16.9 ± 5.75; CON: 14.2 ± 3.4, p = 0.121). Univariable analyses showed lower fatigue in EBCS was associated with better Physical and Mental Health (both R 2  = 0.435; p < 0.01), better outcome expectations for exercise (R 2  = 0.237; p < 0.01), better self-efficacy (R 2  = 0.407; p < 0.01), lower depression (R 2  = 0.383; p < 0.001), lower anxiety (R 2  = 0.104; p < 0.05), and better balance (R 2  = 0.265; p < 0.01). Lower fatigue in the CON group was associated with better sleep quality (R 2  = 0.263; p < 0.05) and self-efficacy (R 2  = 0.417; p < 0.05)., Conclusions: Mild fatigue was prevalent in EBCS, whereas moderate/severe fatigue was not. This discrepancy should be explored provided the benefits of exercise for fatigue management. Further, fatigue in EBCS was associated with multiple psychosocial and functional outcomes, which emphasized both its multi-factorial nature and uniqueness to the EBCS population., Clinicaltrials: gov Number: NCT03760536., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Potential links between a history of sport-related concussions and later-life neurobiological and psychological brain health have been studied in former collision-sport athletes. However, empirical studies of how former athletes perceive the future of their brain health as a result of these injuries are missing., Objectives: We aimed to (1) identify the extent to which former National Football League players currently have concerns about their long-term psychological and cognitive functioning as a result of concussions sustained while playing football; (2) examine whether current concerns are different than concerns they had while playing football; (3) examine the relationship between current brain health concerns and self-reported concussion history (SR-CHx); and (4) explore other important factors associated with these concerns., Methods: In this cross-sectional study, former National Football League players with a SR-CHx of one or more concussions (n = 1514; aged mean [standard deviation] = 52.3 [15.7] years) completed a general health questionnaire. Participants reported their lifetime concussion history, as well as both their current concerns and concerns while playing football (i.e., retrospective concerns) regarding the long-term effects of concussions on their memory, thinking skills, and risk of developing chronic traumatic encephalopathy. Current and retrospective concerns were self-reported on a five-point Likert scale. Four concussion history categories were created based on SR-CHx: 1-2 (n = 309); 3-5 (n = 413); 6-9 (n = 356); and 10 + (n = 436) lifetime concussions. Proportions of participants reporting each level of current and retrospective concerns were examined to identify whether concerns presently exist in these former players, and whether their current concerns are different than retrospective concerns. Next, we explored associations between current concerns and SR-CHx., Results: More than one-third of participants reported being currently "extremely concerned" about memory problems (36.9%), thinking skills (37.8%), and developing chronic traumatic encephalopathy (39.5%). In contrast, when asked about concerns while playing, most reported being "not at all concerned" regarding memory = 61.2%, thinking skills = 56.1%, and developing chronic traumatic encephalopathy = 71.2%. Of those who retrospectively endorsed being "not at all" or "slightly" concerned regarding memory (n = 1159/1514), thinking skills (n = 1080/1514), and developing chronic traumatic encephalopathy (n = 1219/1514), approximately half reported being currently "moderately" or "extremely" concerned about those same issues (n = 586/1159; n = 534/1080; n = 619/1219, respectively). Current concerns regarding memory (χ 2 16  = 316.61; p < 0.001; V = 0.264), thinking skills (χ 2 16  = 333.17; p < 0.001; V = 0.271), and developing chronic traumatic encephalopathy (χ 2 16  = 280.85; p < 0.001; V = 0.249) were significantly related to SR-CHx, with more concussions being associated with greater current concerns., Conclusions: Former National Football League players reported significant concerns regarding the potential effects of their prior concussions on long-term brain health, and these concerns are more prevalent now than when they were playing football. Cognitive and mental health concerns are readily identifiable targets for clinical intervention. Clinicians working with former players may wish to explore the extent to which individual players experience these concerns, the nature and depth of these concerns, and the impact of these concerns on the player's functioning and well-being., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Transition from professional sport to nonsport endeavors has implications for postcareer health and well-being of athletes. The purpose of the current study was to examine associations among transition-related psychosocial factors and current mental health outcomes in former National Football League (NFL) players. Participants were former NFL players (n = 1,784; mean age = 52.3 ± 16.3 years) who responded to a questionnaire assessing the nature of their discontinuation from professional football (i.e., any degree of voluntary choice vs. forced discontinuation), prediscontinuation transition planning (yes vs. no), and current symptoms of depression and anxiety. After adjusting for relevant covariates, having an involuntary discontinuation and no transition plan prior to discontinuation were associated with greater depressive and anxiety symptom severity. Autonomy in discontinuation and pretransition planning are important to former NFL football players' mental health. Increasing autonomy in the discontinuation decision and pretransition planning represent psychoeducational intervention targets for this population.

Objective: This study investigated the longitudinal course of depressive symptom severity over 19 years in former American football players and the influence of concussion history, contact sport participation and physical function on observed trajectories., Methods: Former American football players completed a general health questionnaire involving demographic information, medical/psychiatric history, concussion/football history and validated measures of depression and physical function at three time points (2001, 2010 and 2019). Parallel process latent growth curve modelling tested associations between concussion history, years of football participation, and overall and change in physical function on the overall level and trajectory of depressive symptoms., Results: Among the 333 participants (mean(SD) age, 48.95 (9.37) at enrolment), there was a statistically significant, but small increase in depressive symptom severity from 2001 (48.34 (7.75)) to 2019 (49.77 (9.52)), slope=0.079 (SE=0.11), p=0.007. Those with greater concussion history endorsed greater overall depressive symptom severity, B=1.38 (SE=0.33), p<0.001. Concussion history, B<0.001 (SE=0.02), p=0.997 and years of participation, B<0.001 (SE=0.01), p=0.980, were not associated with rate of change (slope factor) over 19 years. Greater decline in physical function, B=-0.71 (SE=0.16), p<0.001, was predictive of a faster growth rate (ie, steeper increase) of depression symptom endorsement over time., Conclusions: Concussion history, not years of participation, was associated with greater depressive symptom severity. Neither factor was predictive of changes over a 19-year period. Decline in physical function was a significant predictor of a steeper trajectory of increased depressive symptoms, independent of concussion effects. This represents one viable target for preventative intervention to mitigate long-term neuropsychiatric difficulties associated with concussion across subsequent decades of life., Competing Interests: Competing interests: BLB acknowledges support from the National Institute of Neurological Disorders and Stroke (Award Number L30NS113158-02) and National Institute on Aging (Award Number K23 AG073528).ZYK reports grants from National Institutes of Health; grants from Centers for Disease Control and Prevention; and grants from National Football League. AC discloses funding from the National Collegiate Athletic Association. RM reports grants from U.S. Department of Defense; grants from NFL Foundation; and grants from National Institute of Neurological Disorders and Stroke. RE is a paid consultant for the NHL and co-chair of the NHL/NHLPA Concussion Subcommittee. He is also a paid consultant for Major League Soccer and Princeton University Athletic Medicine and occasionally provides expert testimony in matters related to MTBI and sports concussion. WM receives royalties from (1) ABC-Clio publishing for the sale of his books, Kids, Sports and Concussion: A guide for coaches and parents, and Concussions; (2) Springer International for the book Head and Neck Injuries in Young Athlete and (3) Wolters Kluwer for working as an author for UpToDate. His research is funded, in part, by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament and a grant from the National Football League.Dr Guskiewicz reports compensation from National Collegiate Athletic Association for other services and grants from Boston Children's Hospital (sub-award from the National Football League). MM acknowledges researching funding from the NIH, US Dept. of Defense, CDC, NCAA and NFL to the Medical College of Wisconsin., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This study aimed to estimate prevalence of mild cognitive impairment (MCI) and dementia diagnoses in former National Football League (NFL) players ≥50 yr old and examine the relationships among these diagnoses and an array of predictors of long-term brain health., Methods: A cross section of former NFL players (n = 922; mean ± SD age, 64.8 ± 8.9 yr) completed a questionnaire. Prevalence of self-reported medical diagnoses of MCI and dementia was reported alongside U.S. population estimates across 5-yr age intervals (e.g., 60-64 yr). Prevalence ratios (PR) were calculated for multiple predictors of long-term brain health., Results: Overall, MCI prevalence and dementia prevalence were n = 219(23.8%) and n = 82(8.9%), respectively. Each diagnosis was more prevalent in former NFL players across age-groups than U.S. norms, with greater disparities at relatively younger ages (e.g., 65-69 yr) compared with older ages. Greater prevalence of MCI and dementia was associated with self-reported concussion history (10+ vs 0; PRadjusted [95% CI] = 1.66 [1.02-2.71] and 2.61 [1.01-6.71], respectively); recent pain intensity (PRadjusted [95% CI] = 1.13 [1.07-1.20] and 1.15 [1.03-1.28]); and diagnoses of depression (PRadjusted [95% CI] = 2.70 [1.92-3.81] and 3.22 [1.69-6.14]), anxiety (PRadjusted [95% CI] = 1.96 [1.26-3.07] and 3.14 [1.47-6.74]), or both (PRadjusted [95% CI] = 3.11 [2.38-4.08] and 4.43 [2.71-7.25]). Higher MCI prevalence was related to sleep apnea (PRadjusted [95% CI] = 1.30 [1.06-1.60]); higher dementia prevalence was associated with age (5-yr interval, PRadjusted [95% CI] = 1.42 [1.26-1.60]) and race (non-White vs White, PRadjusted [95% CI] = 1.64 [1.07-2.53])., Conclusions: Self-reported MCI prevalence and dementia prevalence were higher in former NFL players than national estimates and were associated with numerous personal factors, including mood-related disorders and a high number of self-reported concussions. Predictors of higher MCI and dementia prevalence may be modifiable and warrant consideration by clinicians and researchers as potential targets to mitigate the onset of these conditions., (Copyright © 2021 by the American College of Sports Medicine.)

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

Purpose: This study examined worker characteristics and behaviors and the perceived importance of job-related tasks associated with the willingness to perform a proposed probation officer physical ability test (PROPAT)., Methods: North Carolina probation officers (N = 1213, 46.2% female, 39.8 ± 10.1 yr, 30.7 ± 6.6 kg·m-2) completed a survey including demographics, health history, and job-related tasks. A multivariable logistic regression model estimated the odds of being willing to perform the PROPAT. Adjusted odds ratios (ORadjusted) with 95% confidence intervals (CI) were calculated, with those excluding 1.00 deemed statistically significant., Results: The majority (72%) of probation officers were willing to perform the PROPAT. Being male (compared with female) (ORadjusted = 1.50, 95% CI = 1.12-2.02) and having moderate (ORadjusted = 1.51, 95% CI = 1.10-2.08) and high physical activity status (ORadjusted = 2.89, 95% CI = 1.97-4.28) (compared with low) increased the odds of being willing to perform the PROPAT. Additionally, reporting a greater importance of tasks, including running to pursue a suspect (TASKRUN, 1-unit increase, ORadjusted = 1.25, 95% CI = 1.10-1.43) and dragging an unresisting person (TASKDRAG, 1-unit increase, ORadjusted = 1.16, 95% CI = 1.01-1.32), increased the odds of being willing to perform the PROPAT. Increasing age (1-yr increase, ORadjusted = 0.96, 95% CI = 0.94-0.98), class II (ORadjusted = 0.45, 95% CI = 0.28-0.71) and class III obesity (compared with normal weight, ORadjusted = 0.55, 95% CI = 0.32-0.93), and a previous musculoskeletal injury (ORadjusted = 0.57, 95% CI = 0.35-0.93) all decreased the odds of being willing to perform the PROPAT., Conclusions: These results suggest being older, previously injured, obese (body mass index ≥ 35 kg·m-2), and less active is associated with being less willing to participate in the PROPAT, whereas males and reporting a higher importance of the TASKRUN and TASKDRAG activities is associated with being more willing to participate in the PROPAT. Departments can use these findings to identify feasible strategies (e.g., education and physical training) to improve the implementation of physical employment standards., (Copyright © 2021 by the American College of Sports Medicine.)

Primary Objective: To describe the collaborative development of a New Zealand Rugby Concussion Assessment (NZRCA) for primary care and to provide normative baseline data from a representative group of high school rugby players., Methods: This study, conducted over the 2018 and 2019 community rugby season where players were baseline tested during the pre- or start of season period., Results: Data were collected from 1428 players (males n = 1121, females n = 307) with a mean age of 15.9 ± 1.4 years. The mean ± SD symptom severity score was 11.3 ± 8.6, the mean number of endorsed symptoms was 8.5 ± 5.3 and the percentage feeling "normal" was 80.2 ± 15.3%. Only 5.3% of players reported no symptoms at baseline. The most common reported were: 'distracted easily' (72.5%), 'forgetful' (68.5%), and 'often tired' (62.6%). None of the participants achieved a perfect score for the SAC50. The majority of participants (89.7%) passed the tandem gait test with a time of 12.2 ± 1.7 seconds. Age, gender, and ethnicity were associated with NZRCA performance; albeit weakly., Conclusion: This study provides normative reference values for high-school rugby players. These data will aid healthcare providers in their identification of suspected concussion in the absence of individualized baselines.

Background and Purpose: Postmortem and experimental studies indicate a potential association between repeated concussions and stroke risk in older contact sport athletes. We examined the relationship between concussion and stroke history in former National Football League players aged ≥50 years., Methods: Former professional football players aged ≥50 years who played ≥1 year in the National Football League were enrolled in the cross-sectional study. Indirect standardization was used to calculate overall and decade-specific standardized prevalence ratios. Logistic regression using Firth's bias reduction method examined the association between lifetime concussion history 0 (n=119; 12.2%), 1 to 2 (n=152; 15.5%), 3 to 5 (n=242; 24.7%), 6 to 9 (201; 20.5%), and 10+(n=265; 27.1%) and stroke. Adjusted odds ratios for stroke were calculated for concussion history groups, age, and coronary artery disease and/or myocardial infarction., Results: The 979 participants who met inclusion criteria had a mean age of 65.0±9.0 years (range, 50-99). The prevalence of stroke was 3.4% (n=33), significantly lower than expected based on rates of stroke in US men aged 50 and over (standardized prevalence ratio=0.56, Z= -4.56, P <0.001). Greater odds of stroke history were associated with concussion history (10+ versus 0, adjusted odds ratio [95% CI]=5.51 [1.61-28.95]), cardiovascular disease (adjusted odds ratio [95% CI]=2.24 [1.01-4.77]), and age (1-year-increase adjusted odds ratio [95% CI]=1.07 [1.02-1.11])., Conclusions: The prevalence of stroke among former National Football League players aged ≥50 years was lower than the general population, with significantly increased risk among those with 10 or more prior concussions. Findings add to the evidence suggesting that traumatic brain injuries are associated with increased risk of stroke. Clinically, management of cardio- and cerebrovascular health may be pertinent to those with a history of multiple prior concussions.