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Introduction: Ice hockey is a popular global sport with growing participation for boys and girls yet remains a high-risk sport for injury. While the evidence for some risk factors, such as bodychecking policy is well established, other risk factors such as player sex have been understudied. The objectives of this study were to examine factors associated with rates of game-related injury, game-related injury resulting in >7 days of time-loss, and practice-related injury in youth ice hockey., Materials and Methods: Safe2Play was a five-year prospective cohort study (2013-2018). All injuries were identified using validated injury surveillance methodology. Multilevel Poisson regression (adjusting for cluster by team and including multiple imputation of missing covariates) was used to estimate incidence rate ratios (IRRs) for player sex, age group, bodychecking policy, year of play, level of play, weight, previous injury within last 12 months, previous lifetime concussion history, and position., Results: A total of 4418 male and female ice hockey players (representing 6584 player-seasons) participating in under-13 (ages 11-12), under-15 (ages 13-14) and under-18 (ages 15-17) age groups were recruited. There were 1184 game-related and 182 practice-related injuries. Factors associated with game-related injury included female sex (IRR = 1.57; 95% CI: 1.18-2.08), previous injury (IRR = 1.46; 95% CI: 1.26-1.70) and lifetime concussion history (IRR = 1.41; 95% CI: 1.23-1.62). Goaltenders had a lower rate of injury (IRR = 0.54; 95% CI: 0.40-0.72) relative to forwards, as did players exposed to policy disallowing bodychecking in games (IRR = 0.44; 95% CI: 0.35-0.55). Female sex (IRR = 1.90; 95% CI: 1.10-3.28) and lifetime concussion history were also significantly associated with practice-related injury (IRR = 1.53; 95% CI: 1.08-2.18)., Conclusions: Based on data from a large 5-year Canadian youth ice hockey longitudinal cohort, several factors associated with injury were identified. Future injury prevention strategies should consider age, sex, previous concussion and injury history, and body checking leagues. Future research in female youth ice hockey including female-only leagues should be a priority to inform prevention strategies in this understudied population.

Context: Few studies utilize randomized clinical trials (RCT) to quantify clinical intervention safety of rehabilitation after sport-related concussion across sport levels., Objective: Describe symptom exacerbation and adverse events (AEs) associated with two concussion rehabilitation interventions., Design: Cluster Randomized Controlled Trial (XXX)., Setting: Sports medicine clinic and field settings., Participants: The RCT enrolled 251 concussed athletes (median age=20 years; female n=48) across 28 sites from New Zealand professional rugby (n=31), Canadian professional football (n=52), United States (U.S.)/Canadian colleges (n=128) and U.S. high schools (n=40)., Interventions: Two medically supervised interventions: 1) Enhanced Graded Exertion (EGE): international return to sport strategy and sport specific activities only (EGE-only n=119) and 2) Multidimensional Rehabilitation (MDR) followed by EGE: early symptom-directed exercises once symptoms were stable, followed by EGE after symptoms resolved (MDR+EGE n=132)., Main Outcome Measures: Primary outcomes were intrasession total symptom severity score exacerbation and significant intersession (increase 10+ severity points) sustained total symptom severity exacerbation, each measured with a Postconcussion Symptom Scale (132 total severity points on scale). Reported AEs were also described. Activity-based rehabilitation sessions (n=1437) were the primary analysis unit. Frequencies, proportions, medians, and Interquartile Ranges (IQRs) were calculated for outcomes by treatment group., Results: The 251 post-injury participants completed 1437 (MDR+EGE=819, EGE-only=618) activity-based intervention sessions. A total of 110 and 105 participants contributed data (those missing had no documented session data) to at least 1 activity-based session in the MDR+EGE and EGE-only arms respectively. Intrasession symptom exacerbations were equivilantly low in MDR+EGE and EGE-only arms (MDR+EGE: 16.7%, 95% CI:14.1%,19.1%; EGE-only: 15.7%, 95% CI: 12.8%,18.6%). In total, 9/819 MDR+EGE sessions (0.9%) and 1/618 EGE-only sessions (0.2%) resulted in a pre- to post-session symptom exacerbation beyond a 10+ severity point increase; 8/9 resolved to <10 points by the next session. Two study-related AEs (1 in each arm) were reported., Conclusions: Participants in MDR+EGE and EGE-only activities reported equivalently low rates of symptom exacerbation.

Objective: To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion., Design: Prospective cohort study, Safe to Play (2013-2018)., Setting: Youth hockey leagues in Alberta and British Columbia, Canada., Participants: Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions., Independent Variables: Psychosocial variables., Main Outcome Measures: Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit., Results: Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery., Conclusions: Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery., Competing Interests: Brian Brooks receives royalties for the sales of the Pediatric Forensic Neuropsychology textbook (Oxford University Press), royalties for 3 pediatric neuropsychological tests [Child and Adolescent Memory Profile (ChAMP, Sherman and Brooks, 2015, PAR Inc), Memory Validity Profile (MVP, Sherman and Brooks, 2015, PAR Inc), and Multidimensional Everyday Memory Ratings for Youth (MEMRY, Sherman and Brooks, 2017, PAR Inc)], and has a private practice where he evaluates youth and professional hockey players with concussion. For the remaining authors, no conflicts of interest were noted. We acknowledge funding from the Canadian Institutes of Health Research and Hotchkiss Brain Institute., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To examine factors associated with rates of game and practice-related concussion in youth ice hockey., Design: Five-year prospective cohort (Safe2Play)., Setting: Community arenas (2013-2018)., Participants: Four thousand eighteen male and 405 female ice hockey players (6584 player-seasons) participating in Under-13 (ages 11-12), Under-15 (ages 13-14), and Under-18 (ages 15-17) age groups., Assessment of Risk Factors: Bodychecking policy, age group, year of play, level of play, previous injury in the previous year, lifetime concussion history, sex, player weight, and playing position., Main Outcome Measurements: All game-related concussions were identified using validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician for diagnosis and management. Multilevel Poisson regression analysis including multiple imputation of missing covariates estimated incidence rate ratios (IRRs)., Main Results: A total of 554 game and 63 practice-related concussions were sustained over the 5 years. Female players (IRR Female/Male = 1.79; 95% CI: 1.26-2.53), playing in lower levels of play (IRR = 1.40; 95% CI: 1.10-1.77), and those with a previous injury (IRR = 1.46; 95% CI: 1.13, 1.88) or lifetime concussion history (IRR = 1.64; 95% CI: 1.34-2.00) had higher rates of game-related concussion. Policy disallowing bodychecking in games (IRR = 0.54; 95% CI: 0.40-0.72) and being a goaltender (IRR Goaltenders/Forwards = 0.57; 95% CI: 0.38-0.87) were protective against game-related concussion. Female sex was also associated with a higher practice-related concussion rate (IRR Female/Male = 2.63; 95% CI: 1.24-5.59)., Conclusions: In the largest Canadian youth ice hockey longitudinal cohort to date, female players (despite policy disallowing bodychecking), players participating in lower levels of play, and those with an injury or concussion history had higher rates of concussion. Goalies and players in leagues that disallowed bodychecking had lower rates. Policy prohibiting bodychecking remains an effective concussion prevention strategy in youth ice hockey., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the association between self-reported and parent-reported attention problems and hyperactivity and rates of injury and concussion in Canadian youth ice hockey players., Design: Secondary analyses of 2 prospective cohort studies., Setting: Canadian youth ice hockey teams., Participants: Ice hockey players (ages 11-17 years) were recruited by team, over 4 seasons (2011-2016). A combined 1709 players contributing 1996 player-seasons were analyzed (257 players participated in more than one season)., Assessment of Risk Factors: Data were collected from preseason baseline questionnaires, including child and parent proxy forms of the Behavior Assessment System for Children, second edition., Main Outcome Measures: Injury and concussion rates and incidence rate ratios (IRR) comparing players with and without self-identified or parent-identified attention problems and hyperactivity, adjusted for covariates (ie, body checking policy, previous injury/concussion, and age) and a random effect for team, were estimated using multiple multilevel negative binomial regression., Results: When analyzed continuously, rates of concussion increased with higher self-reported and parent-reported measures of attention problems [IRR SELF = 1.025; 95% confidence interval (CI): 1.011-1.040; IRR PARENT = 1.032; 95% CI: 1.008-1.057]. Self-reported hyperactivity was significantly associated with concussion (IRR = 1.021; 95% CI: 1.007-1.035), but parent-reported hyperactivity was not (IRR = 1.005; 95% CI: 0.983-1.028). A T score ≥ 60 cutoff combining attention problems and hyperactivity scores (an estimate of probable attention-deficit hyperactivity disorder) was not significantly associated with rates of injury or concussion., Conclusions: Attention problems and hyperactivity may place youth ice hockey players at increased risk of concussion and injury. Preseason assessments could identify players for targeted concussion education and risk reduction strategies., Competing Interests: K. O. Yeates receives book royalties from Guilford Publications, Cambridge University Press, and Taylor & Francis, research grants from the Canadian Institutes of Health Research, and an editorial stipend from the American Psychological Association. B. L. Brooks reports the following conflict of interest: He is a coauthor of the Child and Adolescent Memory Profile (ChAMP, Sherman and Brooks, 2015, PAR, Inc), Memory Validity Profile (MVP; Sherman and Brooks, 2015, PAR, Inc), and Multidimensional Everyday Memory Ratings for Youth (MEMRY, Sherman and Brooks, 2017, PAR, Inc), and he receives royalties for the sales of these tests; he is a coeditor of the Pediatric Forensic Neuropsychology textbook (2012, Oxford University Press) and receives royalties for the sales of this book; and he has previously been provided with free test credits from CNS Vital Signs as an in-kind support for his research. Brian Brooks also acknowledges that he receives funding as a principal investigator, coinvestigator, and collaborator for research projects on concussion and has received honoraria for talks on concussion. For the remaining authors, none were declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To compare rates of injury and concussion among U-15 (ages 13-14 years) ice hockey players playing in leagues allowing body checking, but who have a varying number of years of body checking experience., Methods: This 5-year longitudinal cohort included U-15 ice hockey players playing in leagues where policy allowed body checking. Years of body checking experience were classified based on national/local body checking policy. All ice hockey game-related injuries were identified using a validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician. Multiple multilevel Poisson regression analysis was performed, adjusting for important covariates and a random effect at a team level (offset by game exposure hours), to estimate injury and concussion incidence rate ratios (IRRs)., Results: In total, 1647 players participated, contributing 1842 player-seasons (195 players participating in two seasons). Relative to no body checking experience, no significant differences were found in the adjusted IRRs for game-related injury for players with 1 year (IRR=1.06; 95% CI: 0.77 to 1.45) or 2+ years (IRR=1.16; 95% CI: 0.74 to 1.84) body checking experience. Similarly, no differences were found in the rates of concussion for players with 1 year (IRR=0.92; 95% CI: 0.59 to 1.42) or 2+ years (IRR=0.69; 95% CI: 0.38 to 1.25) body checking experience., Conclusions: Among ice hockey players aged 13-14 years participating in leagues permitting body checking, the adjusted rates of all injury and concussion were not significantly different between those that had body checking experience and those that did not. Based on these findings, no association was found between body checking experience and rates of injury or concussion specifically in adolescent ice hockey., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To document the occurrence and recovery outcomes of sports-related concussions (SRCs) presenting to the Emergency Department (ED) in a community-based sample., Design: A prospective observational cohort study was conducted in 3 Canadian hospitals., Setting: Emergency Department., Patients: Adults (≥17 years) presenting with a concussion to participating EDs with a Glasgow Coma Scale score ≥13 were recruited., Interventions: Patient demographics (eg, age and sex), clinical characteristics (eg, history of depression or anxiety), injury characteristics (eg, injury mechanisms and loss of consciousness and duration), and ED management and outcomes (eg, imaging, consultations, and ED length of stay) were collected., Main Outcome Measures: Patients' self-reported persistent concussion symptoms, return to physical activity status, and health-related quality of life at 30 and 90 days after ED discharge., Results: Overall, 248 patients were enrolled, and 25% had a SRC. Patients with SRCs were younger and reported more physical activity before the event. Although most of the patients with SRCs returned to their normal physical activities at 30 days, postconcussive symptoms persisted in 40% at 90 days of follow-up. After adjustment, there was no significant association between SRCs and persistent symptoms; however, patients with concussion from motor vehicle collisions were more likely to have persistent symptoms., Conclusion: Although physically active individuals may recover faster after a concussion, patients returning to their physical activities before full resolution of symptoms are at higher risk of persistent symptoms and further injury. Patient-clinician communications and tailored recommendations should be encouraged to guide appropriate acute management of concussions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Although high rates of injury occur in youth ice hockey, disagreements exist about the risks and benefits of permitting bodychecking. We sought to evaluate associations between experience with bodychecking and rates of injury and concussion among ice hockey players aged 15-17 years., Methods: We obtained data from a prospective cohort study of ice hockey players aged 15-17 years in Alberta who played in leagues that permitted bodychecking. We collected data over 3 seasons of play (2015/16-2017/18). We compared players based on experience with bodychecking (≤ 2 v. ≥ 3 yr), estimated using local and national bodychecking policy and region of play. We used validated methodology of ice hockey injury surveillance to identify all injuries related to ice hockey games and defined concussions according to the Consensus Statement on Concussion in Sport., Results: We included 941 players who contributed to 1168 player-seasons, with 205 players participating in more than 1 season. Compared with players with 2 years or less of bodychecking experience, those with 3 or more years of experience had higher rates of all injury (adjusted incidence rate ratio [IRR] 2.55, 95% confidence interval [CI] 1.57-4.14), injury with more than 7 days of time loss (adjusted IRR 2.65, 95% CI 1.50-4.68) and concussion (adjusted IRR 2.69, 95% CI 1.34-5.42)., Interpretation: Among ice hockey players aged 15-17 years who participated in leagues permitting bodychecking, more experience with bodychecking did not protect against injury. This provides further support for removing bodychecking from youth ice hockey., Competing Interests: Competing interests: No competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

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.)

Objectives: The objective of this study is to evaluate the effect of policy change disallowing body checking in adolescent ice hockey leagues (ages 15-17) on reducing rates of injury and concussion., Methods: This is a prospective cohort study. Players 15-17 years-old were recruited from teams in non-elite divisions of play (lower 40%-70% by division of play depending on year and city of play in leagues where policy permits or prohibit body checking in Alberta and British Columbia, Canada (2015-18). A validated injury surveillance methodology supported baseline, exposure-hours and injury data collection. Any player with a suspected concussion was referred to a study physician. Primary outcomes include game-related injuries, game-related injuries (>7 days time loss), game-related concussions and game-related concussions (>10 days time loss)., Results: 44 teams (453 player-seasons) from non-body checking and 52 teams (674 player-seasons) from body checking leagues participated. In body checking leagues there were 213 injuries (69 concussions) and in non-body checking leagues 40 injuries (18 concussions) during games. Based on multiple multilevel mixed-effects Poisson regression analyses, policy prohibiting body checking was associated with a lower rate of injury (incidence rate ratio (IRR): 0.38 (95% CI 0.24 to 0.6)) and concussion (IRR: 0.49; 95% CI 0.26 to 0.89). This translates to an absolute rate reduction of 7.82 injuries/1000 game-hours (95% CI 2.74 to 12.9) and the prevention of 7326 injuries (95% CI 2570 to 12083) in Canada annually., Conclusions: The rate of injury was 62% lower (concussion 51% lower) in leagues not permitting body checking in non-elite 15-17 years old leagues highlighting the potential public health impact of policy prohibiting body checking in older adolescent ice hockey players., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. Given infrequent study of concussion symptoms in the general adult population, the authors conducted a sex-based comparison of patients with concussion., Methods: Adults (≥ 17 years of age) presenting with concussion to one of three urban Canadian EDs were recruited. Discharged patients were contacted by telephone 30 and 90 days later to capture the extent of persistent postconcussion symptoms using the Rivermead Post Concussion Symptoms Questionnaire (RPQ). A multivariate logistic regression model for persistent symptoms that included biological sex was developed., Results: Overall, 250 patients were included; 131 (52%) were women, and the median age of women was significantly higher than that of men (40 vs 32 years). Women had higher RPQ scores at baseline (p < 0.001) and the 30-day follow-up (p = 0.001); this difference resolved by 90 days. The multivariate logistic regression identified that women, patients having a history of sleep disorder, and those presenting to the ED with concussions after a motor vehicle collision were more likely to experience persistent symptoms., Conclusions: In a community concussion sample, inconsequential demographic differences existed between adult women and men on ED presentation. Based on self-reported and objective outcomes, work and daily activities may be more affected by concussion and persistent postconcussion symptoms for women than men. Further analysis of these differences is required to identify different treatment options and ensure adequate care and management of injury.

Background: While postural control impairment is common following sport-related concussion, few investigations have studied the physiological basis for this impairment. Both the Reflex/Hierarchical Model and the Systems Model are commonly used to characterize the physiological basis of postural control. Purpose: To discuss the physiological basis of postural control impairment resulting from sport-related concussion based on these models and suggest directions for future research. Methods: Narrative literature review. Findings: Postural control impairment seen with sport-related concussion is a multifaceted construct that can result from deficits in numerous systems that underlie postural control as described by the Systems Model, rather than a unidimensional construct that stems from the central nervous systems' inability to integrate sensory input to control posture as per the Reflex/Hierarchical Model. Conclusion: We recommend a transition away from the Hierarchical/Reflex Model of postural control towards the Systems Model in the conceptualization of sport-related concussion. Future research on postural control following sport-related concussion should account for the multifaceted nature of the resulting postural control impairment based on the Systems Model. Clinically, there is a need for a clinical postural control test that allows examination across the affected systems under single-task, dual-task, and sport-specific paradigms.

Sport-related injuries are the leading cause of injury in youth and are costly to the healthcare system. When body checking is disallowed in non-elite levels of Bantam (ages 13-14 years) ice hockey, the injury rate is reduced, but the impact on costs is unknown. This study compared rates of game injuries and costs among non-elite Bantam ice hockey leagues that disallow body checking to those that did not. Methods : An economic evaluation was conducted alongside a prospective cohort study comparing 608 players from leagues where body checking was allowed in games (Calgary/Edmonton 2014-2015, Edmonton 2015-2016) with 396 players from leagues where it was not allowed in games (Vancouver, Kelowna 2014-2015, Calgary in 2015-2016). The effectiveness measure was rate of game injuries per 1000 player-hours. Costs were estimated based on associated healthcare use within the publicly funded healthcare system as well as privately paid healthcare costs. Probabilistic sensitivity analysis was conducted using bootstrapping. Results: Disallowing body checking reduced the rate of injuries by 4.32 per 1000 player-hours (95% CI -6.92, -1.56) and reduced public and total healthcare system costs by $1556 (95% CI -$2478, -$559) and $1577 (95% CI -$2629, -$500) per 1000 player-hours, respectively. These finding were robust in over 99% of iterations in sensitivity analyses in the public healthcare and the total healthcare system perspectives. There was no statistically significant difference in privately paid healthcare costs (-$65 per 1000 player-hours (95% CI -$220, $99)). Interpretation: Disallowing body checking in non-elite 13-14-year-old ice hockey nationally would prevent injuries and reduce public healthcare costs.

Background: The identification of factors associated with clinical recovery in youth after sports-related concussion could improve prognostication regarding return to play (RTP)., Purpose: To assess factors associated with clinical recovery after concussion in youth ice hockey players., Study Design: Cohort study; Level of evidence, 2., Methods: Participants were part of a larger longitudinal cohort study (the Safe to Play study; N = 3353). Included were 376 ice hockey players (age range, 11-17 years) from teams in Calgary and Edmonton, Canada, with 425 physician-diagnosed ice hockey-related concussions over 5 seasons (2013-2018). Any player with a suspected concussion was referred to a sports medicine physician for diagnosis, and a Sport Concussion Assessment Tool (SCAT) form was completed. Time to clinical recovery was based on time between concussion and physician clearance to RTP. Two accelerated failure time models were used to estimate days to RTP clearance: model 1 considered symptom severity according to the SCAT3/SCAT5 symptom evaluation score (range, 0-132 points), and model 2 considered responses to individual symptom evaluation items (eg, headache, neck pain, dizziness) of none/mild (0-2 points) versus moderate/severe (3-6 points). Other covariates were time to physician first visit (≤7 and >7 days), age group (11-12, 13-14, and 15-17 years), sex, league type (body checking and no body checking), tandem stance (modified Balance Error Scoring System result ≥4 errors out of 10), and number of previous concussions (0, 1, 2, and ≥3)., Results: The complete case analysis (including players without missing covariates) included 329 players (366 diagnosed concussions). The median time to clinical recovery was 18 days. In model 1, longer time to first physician visit (>7 days) (time ratio [TR], 1.637 [95% confidence interval (CI), 1.331-1.996]) and greater symptom severity (TR, 1.016 [95% CI, 1.012-1.020]) were significant predictors of longer clinical recovery. In model 2, longer time to first physician visit (TR, 1.698 [95% CI, 1.399-2.062]), headache (moderate/severe) (TR, 1.319 [95% CI, 1.110-1.568]), and poorer tandem stance (TR, 1.249 [95% CI, 1.052-1.484]) were significant predictors of longer clinical recovery., Conclusion: Medical clearance to RTP was longer for players with >7 days to physician assessment, poorer tandem stance, greater symptom severity, and moderate/severe headache at first visit., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding from Canadian Institutes of Health Research, Alberta Innovates Health Solutions, Hotchkiss Brain Institute, and Alberta Children’s Hospital Foundation. 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., (© The Author(s) 2021.)

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

Objective: To compare rates of injury and concussion among non-elite (lowest 60% by division of play) Bantam (ages 13-14 years) ice hockey leagues that disallow body checking to non-elite Bantam leagues that allow body checking., Methods: In this 2-year cohort study, Bantam non-elite ice hockey players were recruited from leagues where policy allowed body checking in games (Calgary/Edmonton 2014-2015, Edmonton 2015-2016) and where policy disallowed body checking (Kelowna/Vancouver 2014-2015, Calgary 2015-2016). All ice hockey game-related injuries resulting in medical attention, inability to complete a session and/or time loss from hockey were identified using valid injury surveillance methodology. Any player suspected of having concussion was referred to a study physician for diagnosis and management., Results: 49 body checking (608 players) and 33 non-body checking teams (396 players) participated. There were 129 injuries (incidence rate (IR)=7.98/1000 hours) and 54 concussions (IR=3.34/1000 hours) in the body checking teams in games. After policy change, there were 31 injuries (IR=3.66/1000 hours) and 17 concussions (IR=2.01/1000 hours) in games. Policy disallowing body checking was associated with a lower rate of all injury (adjusted incidence rate ratio (IRR)=0.44; 95% CI: 0.27 to 0.74). The point estimate showed a lower rate of concussion (adjusted IRR=0.6; 95% CI: 0.31 to 1.18), but this was not statistically significant., Conclusion: Policy change disallowing body checking in non-elite Bantam ice hockey resulted in a 56% lower rate of injury. There is growing evidence that disallowing body checking in youth ice hockey is associated with fewer injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The emergency department (ED) is the first point of care for many patients with concussion, and post-concussion syndrome can impact vocational outcomes like successful return to work. Evaluation of concussion in general adult populations is needed., Aims: To document the occurrence and outcomes of work-related concussion presenting to the ED for treatment., Methods: This study enrolled adults presenting with concussion to three urban Canadian EDs. Baseline ED interviews, physician questionnaires and patient phone interviews at 30 and 90 days documented work-related events, ED management, discharge advice, patient adherence and symptom severity. Work-related injury and return to work were modelled using logistic or linear regression, as appropriate., Results: Overall, 172 enrolled workers completed at least one follow-up. Work-related concussions were uncommon (n = 28). Most employees (80%) missed at least 1 day of work (median = 7; interquartile range: 3-14). Most (91%) employees returned to work within 90 days, while 41% reported persistent symptoms. Manual labour and self-reported history of attention deficit hyperactivity disorder were associated with work-related concussion, while days of missed work increased with marital status (divorced), history of sleep disorder and physician's advice to avoid work., Conclusion: Work-related concussions are infrequent; however, most workers who sustain a concussion will miss work, and many return while still experiencing symptoms. Work-related concussion and days of missed work are mainly affected by non-modifiable factors. Workers, employers and the workers' compensation system should take necessary precautions to ensure that workers return to work safely and successfully following a concussion., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: This study examined outcomes from the King Devick (K-D) in athletes with Learning Disabilities (LD) and attention disorders (ADHD)., Methods: A total of 574 professional football players from the Canadian Football League (CFL) completed baseline evaluations with computerized neurocognitive testing (CNT) prior to the 2016 competitive season. Player age, education, history of concussion, LD, and ADHD were analyzed for K-D and Immediate Post Concussion Assessment and Cognitive Testing (ImPACT) performance. A series of analyses of co-variance (ANCOVA's) were used to compare participants with a history of LD and ADHD with history of concussion as a co-variate., Results: Approximately 5% of participants reported a diagnosed history of LD and 13% with ADHD. Performance on the K-D test was not significantly correlated with age, education, or history of concussion but was significantly correlated with history of LD and ADHD. Participants with LD performed approximately 6.9 s slower on the K-D test (t[563] = 4.70, p. = 0.0003) and participants with ADHD were approximately 2 s slower (t[572] = 2.04, p. = 0.04)., Conclusions: Results indicated that players with a history of diagnosed LD and ADHD performed slower on the K-D test in comparison to athletes with no history of diagnoses. The results of this study underscore the importance of recognizing individualized outcomes when using the K-D., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: Patients with concussion commonly present to the emergency department (ED) for assessment. Misdiagnosis of concussion has been documented in children and likely impacts treatment and discharge instructions. This study aimed to examine diagnosis of concussion in a general adult population., Methods: Patients >17years old presenting meeting the World Health Organization's definition of concussion were recruited in one academic (Hospital 1) and two community (Hospitals 2 and 3) EDs in a Canadian city. A physician questionnaire and patient interviews documented recommendations given by emergency physicians. Bi-variable comparisons are reported using chi-square tests, t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods., Results: Overall, the study enrolled 250 patients. The median age was 35 (IQR: 23 to 49) and 52% were female. A variety of concussion causes were documented. Forty-one (16%) patients were not diagnosed with a concussion despite meeting criteria. Concussion diagnosis was less likely with a longer ED length of stay (OR=0.71; 95% CI: 0.60 to 0.83), presenting to the non-academic centers (Hospital 2: OR=0.21, 95% CI: 0.08 to 0.58; Hospital 3: OR=0.07, 95% CI: 0.02 to 0.24), or involvement in a motor vehicle collision (OR=0.11; 95% CI: 0.03 to 0.46)., Conclusion: One in six patients with concussion signs and symptoms were misdiagnosed in the ED. Misdiagnosis was related to injury mechanism, length of stay, and enrolment site. Closer examination of institutional factors is needed to identify effective strategies to promote accurate diagnosis of concussion., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Sideline assessment tools are an important component of concussion evaluations. To date, there has been little data evaluating the clinical utility of these tests in professional football. The purpose of this study was to evaluate the clinical utility of the King-Devick (K-D) test in evaluating concussions in professional football players. Baseline data was collected over two consecutive seasons in the Canadian Football League as part of a comprehensive medical baseline evaluation. A pilot study with the K-D test began in 2015 with 306 participants and the next year (2016) there were 917 participants. In addition, a sample of 64 participants completed testing after physical exertion (practice or game). Participants with concussion demonstrated significantly higher (slower) results compared with baseline and the exercise group (F[2,211] = 5.94; p = 0.003). The data revealed a specificity of 84% and sensitivity of 62% for our sample. Reliability from season to season was good (intraclass correlation coefficient [ICC] 2,1 = 0.88; 95% confidence interval [CI]: 0.83, 0.91). On average, participants improved performances by a mean of 1.9 sec (range, -26.6 to 23.8) in subsequent years. High reliability was attained in the exercise group. (ICC2,1 = 0.93; 95% CI: 0.89, 0.96). The K-D test presents as a reliable measure although sensitivity and specificity data from our sample indicate it should be used in conjunction with other measures for diagnosing concussion. Further research is required to identify stability of results over multiple usages.

A critical component for accelerating the clinical uptake of research data in the area of pediatric concussion or mild traumatic brain injury (MTBI) pertains to the establishment and utilization of common databases. The objective of the first phase of our CanPedCDE initiative was to agree upon pediatric common data elements (CDEs) that could best characterize children with MTBI over their recovery period. The selection of CDEs for our framework aimed to balance factors such as the comprehensiveness of outcomes collected, their applicability to diverse settings, as well as the costs associated with their use. Selection began by identifying relevant domains of functioning (e.g., post-concussion symptoms, attention, and balance). Two sources were used to make this process more efficient: 1) the World Health Organization International Classification of Functioning (ICF) Traumatic Brain Injury Core Set, and the U.S. National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Common Data Elements, both of which had already suggested relevant domains to include in TBI research. The process was completed in two phases: 1) using an online survey of experts and 2) through an in-person consensus meeting. Measurement tools were also proposed that were best felt to capture these domains. Forty experts in MTBI in children from multiple health-related perspectives (e.g., emergency medicine, pediatrics, neurosurgery, nursing, physiotherapy, and neuroscience), as well as knowledge users, participated in the selection process. The final list of CDEs included 77 distinct areas of functioning, covering all categories of the ICF model. Outcome measures were attached to each element, when applicable. The CanPedCDE initiative addresses a significant limitation in MTBI research to date and may help both researchers and clinicians to organize and standardize their assessment of children and youth post-MTBI in order to move the field in promising directions.

Background: Patients with mild traumatic brain injury or concussion commonly present to the emergency department for assessment; providing patients with information on usual symptoms and their progression may encourage faster recovery., Objectives: This study aimed to document the role of an electronic clinical practice guideline (eCPG) patient handout on concussion recovery in adult patients discharged from the hospital., Methods: A prospective cohort study was carried out in 3 Canadian urban emergency departments. Adults (≥17 years of age) with a Glasgow Coma Scale score of 13 to 15 who sustained a concussion were recruited by on-site research assistants. Physician use of a concussion-specific eCPG was documented from physician and patient reports. Patient follow-up calls at 30 and 90 days documented return to work/school activities and patient symptoms. Multivariate analyses were performed using logistic regression methods., Results: Overall, 250 patients were enrolled; the median age was 35 (interquartile range 23-49) and 52% were female. Approximately half (n = 119, 48%) of patients received the eCPG handout, and return to work/school recommendations varied. Symptoms persisted in 60% of patients at 30 days; patients in the eCPG group had fewer symptoms (odds ratio 0.57, 95% confidence interval 0.33-0.99). At 90 days, 40% of patients reported persistent symptoms, with no significant difference between groups., Conclusion: An eCPG handout improved patients' short-term outcomes; however, physician use and adherence to guideline recommendations was low. To further facilitate physician compliance and therefore patient recovery, barriers to use of the eCPG handout need to be identified and addressed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To measure neurocognitive functioning in college and professional football players after game participation., Study Design: Retrospective, cross-sectional cohort design., Participants: Ninety-four male university and professional football players., Intervention: All participants completed Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) testing at baseline, and either at postconcussion (group 1) or postgame (group 2) participation., Main Outcome Measures: Results from the 5 ImPACT composite scores (Verbal Memory, Visual Memory, Visual Motor Speed, Reaction Time and Impulse Control) and Total Symptom Score., Results: Repeated-measures analysis of variance demonstrated a significant main effect for time (improvements) in 3 of 5 domains for the postconcussion group, but no improvements in the postgame group. The postconcussion group presented with significantly improved results on 4 of 5 ImPACT domains compared with the postgame group at the follow-up time interval., Conclusions: Participation in a football game with potential cumulative head contacts did not yield increased symptoms or cognitive impairment. However, the absence of improvement in cognitive functioning in noninjured football players, which was found in those players who were returned to play after an injury, may suggest that there is a measureable impact as a result of playing football.

The objective is to evaluate the psychological outcomes arising from sport concussions. Participants included AA and AAA level Bantam and Midget hockey players (n = 672) between 12 and 17 years of age (mean = 15.0 years; SD = 1.2) enrolled in a large cohort study. All participants completed baseline tests including the Behavior Assessment System for Children, 2nd Edition (BASC2) and a pre-season medical questionnaire (PSQ) completed by parents that included a retrospective report of prior concussions and injuries. Players were assigned to 4 groups: no injury (NONE), concussion (CO) and musculoskeletal (MSK) injuries or both (COMB). Participants in the CO and COMB groups demonstrated significantly higher rates of psychological difficulties compared with other groups [F(63, 1800) = 1.43, p = .016, partial η(2) = 0.05) and on select clinical scales measuring atypicality, locus of control, anxiety, depression, sense of inadequacy, somatization, and attention. In addition, results from the composite clinical scales reached statistical significance for internalizing problems and emotional symptom index. Effect sizes were minimal with the exception of comparisons between the NONE and COMB groups where effect sizes were medium to large. Proportions above clinical cut-off scores set by the BASC2 were higher for the COMB group compared with CO, MSK, or NONE groups. Results suggest smaller percentage of youth may be more prone to psychological sequelae following concussion., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Educating athletes, coaches, parents and healthcare providers about concussion management is a public health priority. There is an abundance of information on sports concussions supported by position statements from governing sport and medical organisations. Yet surveys of athletes, parents, coaches and healthcare providers continue to identify multiple barriers to the successful management of sports concussion. To date, efforts to provide education using empirically sound methodologies are lacking., Purpose: To provide a comprehensive review of scientific research on concussion education efforts and make recommendations for enhancing these efforts., Study Design: Qualitative literature review of sports concussion education., Methods: Databases including PubMed, Sport Discus and MEDLINE were searched using standardised terms, alone and in combination, including 'concussion', 'sport', 'knowledge', 'education' and 'outcome'., Results: Studies measuring the success of education interventions suggest that simply presenting available information may help to increase knowledge about concussions, but it does not produce long-term changes in behaviour among athletes. Currently, no empirical reviews have evaluated the success of commercially available sports concussion applications. The most successful education efforts have taken steps to ensure materials are user-friendly, interactive, utilise more than one modality to present information and are embedded in mandated training programmes or support legislation. Psychosocial theory-driven methods used to understand and improve 'buy in' from intended audiences have shown promise in changing behaviour., Conclusions: More deliberate and methodologically sound steps must be taken to optimise education and knowledge translation efforts in sports concussion., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To evaluate minor hockey players' attitudes and knowledge about sport concussions., Participants: Male and female Pee Wee, Bantam, and Midget level players (n = 183) participating in minor hockey and a comparison group of non-hockey players (n = 57)., Design: Survey., Main Measures: Player knowledge and attitudes were evaluated with a standardized questionnaire developed for the purpose of this study. Descriptive statistics including cross-tabulations and proportion comparisons were used to report the data., Results: Players had foundational knowledge about concussions; however, more than half underestimated the prevalence and more than 30% were unaware of return to play protocols. Although nearly all players knew what they "should" do when concussed, 33% did not follow recommendations. Players reported more concern and appreciation of the seriousness of concussion than non-players, but they tended to minimize their vulnerability. The most common and helpful information sources were parents, doctors, and coaches, and therefore knowledge translation efforts should target theses audiences., Conclusion: Young athletes continue to demonstrate gaps in their knowledge of concussions. In addition, attitudes toward concussion suggest a developmental trajectory with younger athletes being most likely to ignore current recommended guidelines.

Study Design: Cross-sectional., Objective: To examine differences in concussion history and attention or learning disorders reported by elite youth ice hockey players, using a questionnaire that allows parental input compared to a clinic-based test battery that does not., Background: A history of previous concussion and the presence of attention or learning disorders can affect concussion-management decisions; however, youth athletes may not accurately report their medical history because they may not know or recall important details., Methods: The sample included 714 Bantam (ages 12-14 years) and Midget (ages 15-17 years) ice hockey players (601 male, 113 female) from the most elite divisions of play (AA and AAA). Players completed a take-home preseason questionnaire (PSQ) with the input of a parent/guardian, and also independently completed the baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) at the beginning of the 2011-2012 hockey season., Results: In 21.1% (95% confidence interval: 18.1%, 24.1%) of cases, there was disagreement between the PSQ and ImPACT in the number of previous concussions reported. Among those who reported an attention disorder on the PSQ, 85.7% also reported an attention disorder on the ImPACT. Only 9.5% of those who reported a learning disorder on the PSQ also reported a learning disorder on the ImPACT., Conclusion: In 1 of 5 players, reported concussion history differed between the PSQ and ImPACT, and there was substantial disagreement between instruments for those reporting learning disorders. The method of obtaining medical history may, therefore, affect baseline and postconcussion evaluations.

Objective: Sex differences following concussion are poorly understood. The purpose of this study was to examine whether male and female adolescent athletes with prior concussions differ regarding neurocognitive function and symptom reporting., Setting: Community-based hockey teams., Participants: Participants included 615 elite hockey players 13 to 17 years old (mean = 15.5, 95% confidence interval [CI] = 15.4-15.6). There were 517 males and 98 females. Players with English as a second language, attention or learning problems, a concussion within 6 months of baseline, or suspected invalid test profiles were excluded from these analyses., Design: Cross-sectional., Main Measure: Domain scores and symptom ratings from the ImPACT computerized battery., Results: There were no significant neurocognitive differences between males and females with (F5,227 = 1.40, P = .227) or without (F5,376 = 1.33, P = 0.252) a prior history of concussion. Male and female athletes with a history of concussion reported higher raw symptom scores than those without a prior concussion; however, sex differences disappear when symptom scores are adjusted for known sex differences in controls (total score, F2,230 = 0.77, P = .46; Cohen d = 0.01 or domain scores (F4,227 = 1.52, P = .197; Cohen d = 0.07-0.18)., Conclusions: Although those with prior concussions report more symptoms (but do not differ on neurocognition), this study does not support sex differences with cognition or symptoms in adolescent athletes with prior concussions.

This cross-sectional study aimed to determine psychometric properties and reference values for ImPACT in a sample of 704 elite ice hockey players aged 13-17. Baseline ImPACT tests were completed at the beginning of the 2011-2012 season. Players aged 16-17 had better visual motor processing speed, adjusted R(2) = .0522, F(2, 45) = 10.79, β = 2.87, p < .001, and impulse control, adjusted R = .0185, F(2,45) = 7.46, β = -1.35, p = .001, than younger players, and girls had greater total symptom ratings than boys (z = -3.47, p = .0005). There were no other sex- or age-related differences in neurocognitive performance, and no effect of previous concussion on ImPACT scores. Reference values with cut-off scores are presented.

Context: Variables that may influence baseline concussion symptoms should be investigated., Objective: To evaluate the effect of physical fitness on self-report of baseline concussion symptoms in collegiate athletes and students., Design: Controlled laboratory study., Patients or Other Participants: A total of 125 undergraduates, including 95 collegiate athletes and 30 recreational athletes (83 males, 42 females)., Intervention(s): Participants completed the Standardized Concussion Assessment Tool 2 (SCAT2; symptom report) at baseline, within 10 minutes of completing the Leger test, and within 24 hours of the initial baseline test. The Leger (beep) test is a shuttle-run field test used to predict maximal aerobic power., Main Outcome Measure(s): The total symptom score on the SCAT2 was calculated and analyzed with a repeated-measures analysis of variance. A linear regression analysis was used to determine if 3 variables (sport type, sex, or fitness level) accounted for a significant amount of the variance in the baseline symptom report., Results: Participants reported more symptoms postactivity but fewer symptoms at 24 hours compared with baseline, representing a time effect in our model (F2,234 = 47.738, P < .001). No interactions were seen among the independent variables. We also found an effect for fitness level, with fitter individuals reporting fewer symptoms at all 3 time intervals. The regression analysis revealed that fitness level accounted for a significant amount of the variance in SCAT2 symptoms at baseline (R (2) = 0.22, F3,121 = 11.44, P < .01)., Conclusions: Fitness level affected the baseline concussion symptom report. Exercise seems to induce concussion symptom reporting, and symptom severity may be a function of an athlete's level of conditioning. Sports medicine professionals should consider an athlete's level of fitness when conducting baseline concussion symptom assessments.

The existing literature on lingering effects from concussions in children and adolescents is limited and mixed, and there are no clear answers for patients, clinicians, researchers, or policy makers. The purpose of this study was to examine whether there are lingering effects of past concussions in adolescent athletes. Participants in this study included 643 competitive Bantam and Midget hockey players (most elite 20% by division of play) between 13 and 17 years of age (mean age=15.5, SD=1.2). Concussion history at baseline assessment was retrospectively documented using a pre-season questionnaire (PSQ), which was completed at home by parents and players in advance of baseline testing. Players with English as a second language, self-reported attention or learning disorders, a concussion within 6 months of baseline, or suspected invalid test profiles were excluded from these analyses. Demographically adjusted standard scores for the five composites/domains and raw symptom ratings from the brief Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computerized battery were analyzed. Adolescent athletes with one or two or more prior concussions did not have significantly worse neurocognitive functioning on ImPACT than did those with no previous concussions. There were significantly more symptoms reported in those with two or more prior concussions than in those with no or one prior concussion. Adolescents with multiple previous concussions had higher levels of baseline symptoms, but there were not group differences in neurocognitive functioning using this brief computerized battery.

Context: Evolving concussion diagnosis/management tools and guidelines make Knowledge Transfer and Exchange (KTE) to practitioners challenging., Objective: Identify sports concussion knowledge base and practise patterns in two family physician populations; explore current/preferred methods of KTE., Design: A cross-sectional study., Setting: Family physicians in Alberta, Canada (CAN) and North/South Dakota, USA., Participants: CAN physicians were recruited by mail: 2.5% response rate (80/3154); US physicians through a database: 20% response rate (109/545). INTERVENTION/INSTRUMENT: Online survey. MAIN AND SECONDARY OUTCOME MEASURES: Diagnosis/management strategies for concussions, and current/preferred KTE., Results: Main reported aetiologies: sports/recreation (52.5% CAN); organised sports (76.5% US). Most physicians used clinical examination (93.8% CAN, 88.1% US); far fewer used the Sport Concussion Assessment Tool (SCAT1/SCAT2) and balance testing. More US physicians initially used concussion-grading scales (26.7% vs 8.8% CAN, p=0.002); computerised neurocognitive testing (19.8% vs 1.3% CAN; p<0.001) and Standardised Assessment of Concussion (SAC) (21.8% vs 7.5% CAN; p=0.008). Most prescribed physical rest (83.8% CAN, 75.5% US), while fewer recommended cognitive rest (47.5% CAN, 28.4% US; p=0.008). Return-to-play decisions were based primarily on clinical examination (89.1% US, 73.8% CAN; p=0.007); US physicians relied more on neurocognitive testing (29.7% vs 5.0% CAN; p<0.001) and recognised guidelines (63.4% vs 23.8% CAN; p<0.001). One-third of Canadian physicians received KTE from colleagues, websites and medical school training. Leading KTE preferences included Continuing Medical Education (CME) courses and online CME., Conclusions: Existing published recommendations regarding diagnosis/management of concussion are not always translated into practise, particularly the recommendation for cognitive rest; predicating enhanced, innovative CME initiatives.

Objective: The objective of this study was to investigate minor hockey coaches' knowledge base of sport-related concussions., Design: Cross-sectional survey., Setting: Subjects independently completed the written survey at preseason organizational meetings., Participants: One hundred seventy-eight active coaches spanning 5 age levels (ages 5-15 years). Coaches reported 2.62 ± 3.73 years of coaching experience., Main Outcome Measures: Resources where coaches obtained information about concussions, perceptions of variables associated with concussions, knowledge level of issues associated with concussions, and decision-making practices., Results: Newspapers and magazines were the most frequent source of information regarding concussions, yet were rated as not very helpful. Family physicians were less frequently sought but were rated as most helpful. A majority of coaches reported limited knowledge about concussions but rated this knowledge as being important. There was a significant relationship between head coaching experience and concussion knowledge [R = 0.09, F3,156 = 4.41, P = 0.005]. Most coaches demonstrated a good knowledge base of common issues associated with concussions, and a majority of individuals correctly identified return-to-play practices., Conclusions: A majority of minor hockey coaches correctly recognized and understood issues related to sport-related concussions. Results suggested that knowledge translation through various formal and informal sources has had a positive effect. However, a majority of coaches reported having limited knowledge about concussions yet consider it an important topic.

Context: Monitoring of subjective symptoms is the foundation of all sport concussion management programmes. The purpose of this study is to examine methodological variables that impact symptom reporting during baseline testing., Objective: To investigate how the administration method of a concussion assessment tool (self-report vs interview) affects the report of symptoms., Design, Setting and Participants: This was a cross-sectional, semi-randomized study of 117 athletes., Main Outcome Measurements: Subjects completed the Post-Concussion Scale during pre-season evaluations., Results: A two-factor ANOVA revealed a significant difference in total symptom scores (p = 0.02) and number of endorsed symptoms (p = 0.02) across administration modes. Athletes had a greater total symptom score and reported a greater number of symptoms in the self-administration condition than in the interview condition. Furthermore, there was a significant difference in symptom reporting across interviewer gender. Athletes endorsed more symptoms when the interviewer was a woman., Conclusions: Because the method of collecting symptoms, as well as interviewer gender, can impact test results, self-report measures may be a better way of obtaining consistent results. Clinicians and researchers should be aware that both the nature and extent of symptom reporting is greater when using questionnaires than when athletes are interviewed.

Objectives: This study sought to determine the incidence of delayed diagnosis of intracranial hemorrhage in the general population and the proportion of children who presented to emergency departments (EDs) with uncomplicated minor head injuries who received delayed diagnoses of intracranial hemorrhage., Methods: This was an 8-year, retrospective, cohort study of children <14 years of age who presented to EDs in the Calgary Health Region between April 1992 and March 2000. Cases of uncomplicated minor head injuries and delayed diagnosis of intracranial hemorrhage (intracranial hemorrhage not apparent until > or =6 hours after injury) were identified., Results: An estimated 17,962 children (95% confidence interval [CI]: 17,412-18,511 children) with uncomplicated minor head injuries were evaluated at Calgary Health Region EDs. Two and 8 children were identified as having delayed diagnoses of intracranial hemorrhage with and without delayed deterioration in level of consciousness (Glasgow Coma Scale scores of <15), respectively. The proportions of children with uncomplicated minor head injuries with delayed diagnoses of intracranial hemorrhage with and without deterioration in level of consciousness were approximately 0.00% (0 of 17,962 children [upper limit of 95% CI: 0.02%]) and 0.03% (5 of 17,962 children [95% CI: 0.01%-0.07%]), respectively. On the basis of population data for the Calgary Health Region, the incidences of delayed diagnosis of intracranial hemorrhage with and without deterioration in level of consciousness were 0.14 and 0.57 cases per 100,000 children per year, respectively., Conclusions: The occurrence of delayed diagnosis of intracranial hemorrhage among children who present with uncomplicated minor head injuries is rare.

The oral version of the Trail Making Test (OTMT) is a neuropsychological measure that provides an assessment of sequential set-shifting without the motor and visual demands of the written TMT (WTMT). Originally purposed to serve as an oral analog of the WTMT, the OTMT provides a means to evaluate patients with physical restrictions. However, formal validity studies and available normative data remain sparse. In a sample of healthy adults (n = 81), a strong correlation was observed between OTMT-B and its written counterpart (r = .62), but the correlations were weak between OTMT-A and either written version of the TMT. OTMT-B was significantly correlated with age but not with education or gender, whereas OTMT-A was not significantly correlated with demographic factors. The WTMT to OTMT ratios observed in the current study were generally lower than previously reported and varied across age groups, suggesting that the recommended use of a uniform conversion factor to predict one performance based on the other should be cautiously undertaken. Normative data that have been stratified by age are provided as well as suggestions for using both versions of the TMT in tandem to better elucidate the nature of cognitive deficits and to aid in the localization of cerebral dysfunction.

Context: With increasing knowledge and research about concussion, there have been few objective studies that have used neuropsychological domain scores and postural stability to assess concussion., Objective: To evaluate the recovery curve of athletes who incur sport-related concussion from repeated serial testing of neuropsychological and posturography testing., Design: A prospective epidemiological model was used for the course of the study., Setting: Division I intercollegiate athletics., Participants: Athletes participating in football, soccer, basketball, softball, and cheerleading., Main Outcome Measures: Neuropsychological scores and posturography measures were obtained preseason and serially at day 1, day 2, day 3, and day 10 postconcussion. Control participants were tested at the same intervals. Neuropsychological scores were converted to standards score and then into domains of attention, learning, speed of information processing, concentration, memory, and verbal fluency. Analysis of covariance with the baseline test as the covariate was used to analyze the data with univariate post hoc tests performed., Results: Significant group differences were found for self reported symptoms (P = 0.001), speed of information processing (P = 0.005), mean stability (P = 0.002), and vestibular function (P = 0.003) between injured and control participants. A group, by day, planned comparison found that speed of information processing and composite balance measures demonstrated significant differences through day 10 postinjury, while symptoms and the vestibular ratio remained significant only through day 3., Conclusions: The concussion recovery curve demonstrated short-term neuropsychological and posturography deficits following injury. A comprehensive approach to concussion management should be used to assess the injury and make return-to-play decisions.

Normative data for a healthy sample of older adults (n = 108) ranging in age from 60 to 96 are provided for the Cognistat, a mental status exam previously known as the Neurobehavioral Cognitive Status Examination (NCSE). A Cognistat Composite Score is also introduced that is intended to be used as a marker of general cognitive impairment, allowing the Cognistat to be used to match patients in terms of the severity of their cognitive dysfunction. The "screen and metric" approach of the Cognistat was abandoned in order to improve the reliability and standardization of this measure by administering the entire metric to all patients. The impact of demographic variables on Cognistat performance was examined, demonstrating that both age and education contribute uniquely to a number of Cognistat subtests as well as to the Cognistat Composite Score. This study highlights the importance of matching an examinee's demographic background to the normative sample with which his or her test score is being compared. Normative data were stratified accordingly by age and by both age and education. Current results indicate that the Cognistat is sensitive to normal aging and promises greater sensitivity to the impact of age than the commonly employed Mini-Mental State Examination (MMSE).

Recent evidence suggests significant short-term neurocognitive deficits following mild traumatic brain injury (MTBI) in sports. However, sequelae of mild head injuries is complicated by many factors including a history of multiple head injuries and injury severity. Few studies have considered the influence these variables may have on proper classification of a MTBI and their meaning for return-to-play guidelines. This study presents the short-term neuropsychological and balance outcomes of four college athletes who sustained mild head injuries of different severity (grade I, grade II, grade III and multiple head injured with a grade II based on American Academy of Neurology guidelines). The results demonstrated that self-report symptoms of concussion were slow to resolve in the grade III and multiple concussed individuals. For neuropsychological testing, Trails A & B, Symbol Digit Modalities Test and Digits Span Backwards were the most sensitive in identifying differences between the injuries. For balance assessments using the Neurocom Smart Balance System, the Sensory Organization Test and Reaction Time were also important variables in detecting differences among the various injuries. When these data are used together, it can assist physicians in determining safe return-to-play for athletes who sustain MTBI. There are contradindications in the numerous grading systems and return-to-play guidelines for MTBI. The results from this study provides new evidence which can be assimilated into a valid grading scale for MTBI sustained in sport.