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Context: The abrupt cessation of school and sport participation during the COVID-19 pandemic may have negative implications for adolescent mental health., Objectives: To (1) compare mental, physical, and social health and behaviors during pandemic-related stay-at-home mandates with the same measures collected 1 to 2 years earlier and (2) evaluate the relationships between physical activity and sleep during the pandemic and changes in anxiety, fatigue, and peer relationships between assessment times., Design: Cohort study., Setting: Pediatric sports medicine center., Patients or Other Participants: A total of 39 high school athletes (25 adolescent girls, 14 adolescent boys; age = 16.2 ± 0.9 years)., Main Outcome Measure(s): Patient-Reported Outcome Measurement System anxiety, fatigue, and peer relationships short forms and the Pittsburgh Sleep Quality Index were completed twice (initial assessment in May 2018 or 2019, follow-up assessment in May or June 2020). Frequency and duration of physical activity and frequency of interaction with other individuals (family, peers, sport coaches, etc) were self-reported at follow-up assessment for the 2 weeks before school or sport closure and the 2 weeks before questionnaire completion., Results: Higher levels of anxiety (5.5 ± 4.0 versus 3.6 ± 3.4 points; P = .003) and fatigue (5.4 ± 3.7 versus 2.3 ± 2.5 points; P < .001) and worse sleep quality (6.6 ± 2.9 versus 4.3 ± 2.3 points; P < .001) were observed during the pandemic compared with previous assessments. Reductions in physical activity were noted between assessments (exercise duration: 86.4 ± 41.0 versus 53.8 ± 30.0 minutes; P < .001). Sleep quality but not physical activity during the pandemic predicted changes in fatigue (P = .03, β = 0.44 [95% CI = 0.06, 0.83]) and peer relationships (P = .01, β = -0.65 [95% CI = -1.16, -0.15]) from initial to follow-up assessment., Conclusions: Mental and physical health declined during stay-at-home mandates compared with assessments 1 to 2 years earlier. Physical activity behaviors and sources of social interaction underwent changes after school and sport cessation. Sleep quality may have provided some protection against declining adolescent mental health during the pandemic, although this relationship requires further investigation., (© by the National Athletic Trainers’ Association, Inc.)

Context: Concussion underreporting leads to delays in diagnosis and treatment, prolonging recovery time. Athletes' self-reporting of concussion symptoms, therefore, reduces risk., Objective: To evaluate the effectiveness of 3 concussion-education programs in improving concussion-reporting intention., Design: Randomized controlled clinical trial., Setting: Three high schools in California., Patients or Other Participants: A total of 118 male football players (age = 14.88 ± 1.19 years)., Intervention(s): Participants were randomly assigned to receive concussion education via CrashCourse (CC), Centers for Disease Control and Prevention (CDC) video education materials (CDC-Vi), or CDC written education materials (CDC-Wr)., Main Outcome Measure(s): The primary outcome was concussion-reporting intention, which was assessed at baseline, immediately after education, and at 1-month follow-up. Secondary outcomes were concussion knowledge, concussion-reporting attitudes, perceived concussion-reporting norms, and perceived behavioral control., Results: Across all education formats, a total sample of athletes improved in concussion-reporting intention at immediate and 1-month follow-ups (mean improvements = 6.8% and 11.4%, respectively; F4,224 = 11.1, P < .001). Similar findings were observed across all education formats in secondary analyses examining knowledge, attitudes, and perceived behavioral control. However, we noted differences in concussion-reporting intention by education format and time (F4,224 = 2.8, P = .03). Post hoc analysis showed that athletes who received CC had increased concussion-reporting intentions at immediate and 1-month follow-ups (baseline = 4.7, immediate follow-up = 6.1, 1-month follow-up = 6.0; F16,61.1 = 6.1, P = .007) compared with increases only at 1-month follow-up for CDC-Vi (baseline = 4.3, immediate follow-up = 5.2, 1-month follow-up = 5.8; F1.6,61.6 = 8.4, P = .001) and no improvement for CDC-Wr (P = .10). Secondary analyses indicated differences between CC and both CDC interventions in concussion knowledge and attitudes at immediate and 1-month follow-ups. We identified no differences in perceived behavioral control among interventions (F4,216 = 0.2, P = .93) or perceived concussion-reporting norms across (F4,224 = 0.3, P = .73) or among (F4,224 = 1.7, P = .15) interventions., Conclusions: All athletes exhibited an improved intent to report concussions, increased concussion knowledge, better concussion attitudes, and more perceived behavioral control at both immediate and 1-month follow-ups. However, athletes randomized to receive CC reported a greater intent to report concussion, more knowledge, and improved concussion-reporting attitudes when compared with those who received CDC-Vi and CDC-Wr., (© by the National Athletic Trainers' Association, Inc.)

Context: A growing number of high-school-aged athletes participate on club sport teams. Some, but not all, state concussion laws apply to both interscholastic and private sport organizations. However, concussion education, management plans, and knowledge have not been examined in club coaches who coach high school-aged athletes., Objective: To determine if differences in concussion education, management plans, and knowledge exist between high school coaches and coaches of club sport teams., Design: Cross-sectional study., Setting: Online survey., Patients or Other Participants: A total of 769 coaches (497 high school coaches, 272 club coaches coaching high school-aged athletes; 266 women [34.6%], 503 men [65.4%]) completed an anonymous online questionnaire., Main Outcome Measure(s): The questionnaire consisted of demographic and team information, requirements for concussion-education and -management plans, and concussion knowledge., Results: High school coaches were more likely than club coaches to report that their organizing bodies or leagues required them to receive concussion-education information (97.4% versus 80.4%; P < .001) and that their organizing bodies or leagues had a concussion-management plan (94.0% versus 70.2%; P < .001). High school coaches were more likely than club coaches to correctly agree that most concussions resolve in 7 to 10 days (48.6% versus 40.1%; P = .02) and disagree that loss of consciousness is required to diagnose a concussion (87.1% versus 80.9%; P = .02)., Conclusions: Club coaches were less likely to be aware of requirements for concussion-education and -management plans from their parent organizations and scored lower on specific concussion-knowledge questions than high school coaches despite the same education requirements across groups under their state concussion laws. These results raise concerns regarding the proper management of concussions in club sports and suggest a need for greater oversight and enforcement of state laws in the club sport setting., (© by the National Athletic Trainers' Association, Inc.)

Context: The relative availability of clinicians as well as the types and training of health care providers have been associated with morbidity and mortality in non-athletic health care settings. Whether staffing variations are associated with injury incidence in collegiate athletes is unknown., Objective: To evaluate whether the institutional ratio of athletes to athletic trainers (patient load) or the ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers or both is associated with the incidence of injuries sustained by male ice hockey athletes at the school., Design: Descriptive epidemiology study., Setting: National Collegiate Athletic Association (NCAA) men's ice hockey teams., Patients or Other Participants: Collegiate men's ice hockey athletes., Main Outcome Measure(s): The NCAA Injury Surveillance Program collected data from collegiate men's ice hockey athletes. Staffing patterns were obtained through telephone interviews. Injury counts, injury rates per 1000 athlete-exposures, and injury rate ratios with 95% confidence intervals were calculated and compared between the following groups: (1) schools with high (versus low) patient load and (2) schools with high (versus low) ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers., Results: Both the patient load and relative number of staff athletic trainers were associated with variations in the incidences and types of diagnosed injuries in male ice hockey players. Specifically, fewer injuries were diagnosed by clinicians at institutions with high patient loads. The rates of injury overall and non-time-loss injuries were lower in the high patient-load group. Time-loss injury rates, severe injury rates, concussion rates, and overall rates of injury during competition were greater in the group with a higher proportion of staff athletic trainers, whereas non-time-loss injury rates were lower., Conclusions: In this study of collegiate men's ice hockey players, athlete health outcomes were directly related to the number and types of clinicians available. Future researchers should evaluate whether this finding extends beyond men's ice hockey., (© by the National Athletic Trainers' Association, Inc.)

Context: Structural features of health care environments are associated with patient health outcomes, but these relationships are not well understood in sports medicine., Objective: To evaluate the association between athlete injury outcomes and structural measures of health care at universities: (1) clinicians per athlete, (2) financial model of the sports medicine department, and (3) administrative reporting structure of the sports medicine department., Design: Descriptive epidemiology study., Setting: Collegiate sports medicine programs., Patients or Other Participants: Colleges that contribute data to the National Collegiate Athletic Association (NCAA) Injury Surveillance Program., Main Outcome Measure(s): We combined injury data from the NCAA Injury Surveillance Program, sports medicine staffing data from NCAA Research, athletic department characteristics from the United States Department of Education, and financial and administrative oversight model data from a previous survey. Rates of injury, reinjury, concussion, and time loss (days) in NCAA athletes., Results: Compared with schools that had an average number of clinicians per athlete, schools 1 standard deviation above average had a 9.5% lower injury incidence (103.6 versus 93.7 per 10000 athlete-exposures [AEs]; incidence rate ratio [IRR] = 0.905, P < .001), 2.7% lower incidence of reinjury (10.6 versus 10.3 per 10000 AEs; IRR = 0.973, P = .004), and 6.7% lower incidence of concussion (6.1 versus 5.7 per 10000 AEs; IRR = 0.933, P < .001). Compared with the average, schools that had 1 standard deviation more clinicians per athlete had 16% greater injury time loss (5.0 days versus 4.2 days; IRR = 1.16, P < .001). At schools with sports medicine departments financed by or reporting to the athletics department (or both), athletes had higher injury incidences (31% and 9%, respectively)., Conclusions: The financial and reporting structures of collegiate sports medicine departments as well as the number of clinicians per athlete were associated with injury risk. Increasing the number of sports medicine clinicians on staff and structuring sports medicine departments such that they are financed by and report to a medical institution may reduce athlete injury incidence., (© by the National Athletic Trainers' Association, Inc.)

Context: The ratio of clinicians to patients has been associated with health outcomes in many medical contexts but has not been explored in collegiate sports medicine. The relationship between administrative and financial oversight models and staffing is also unknown., Objective: To (1) evaluate staffing patterns in National Collegiate Athletic Association sports medicine programs and (2) investigate whether staffing was associated with the division of competition, Power 5 conference status, administrative reporting structure (medical or athletic department), or financial structure (medical or athletic department)., Design: Cross-sectional study., Setting: Collegiate sports medicine programs., Patients or Other Participants: Representatives of 325 universities., Main Outcome Measure(s): A telephone survey was conducted during June and July 2015. Participants were asked questions regarding the presence and full-time equivalence of the health care providers on their sports medicine staff. The number of athletes per athletic trainer was determined., Results: Responding sports medicine programs had 0.5 to 20 full-time equivalent staff athletic trainers (median = 4). Staff athletic trainers at participating schools cared for 21 to 525 athletes per clinician (median = 100). Both administrative and financial oversight from a medical department versus the athletics department was associated with improved staffing across multiple metrics. Staffing levels were associated with the division of competition; athletic trainers at Division I schools cared for fewer athletes than athletic trainers at Division II or III schools, on average. The support of graduate assistant and certified intern athletic trainers varied across the sample as did the contributions of nonphysician, nonathletic trainer health care providers., Conclusions: In many health care settings, clinician : patient ratios are associated with patient health outcomes. We found systematic variations in clinician : patient ratios across National Collegiate Athletic Association divisions of competition and across medical versus athletics organizational models, raising the possibility that athletes' health outcomes vary across these contexts. Future researchers should evaluate the relationships between clinician : patient ratios and athletes' access to care, care provision, health care costs, health outcomes, and clinician job satisfaction., (© by the National Athletic Trainers' Association, Inc.)

Context: Data on high school (HS) rowing injuries are lacking., Objective: To describe the epidemiology of HS boys' and girls' rowing injuries during the 2011-2012 through 2013-2014 academic years., Design: Descriptive epidemiology study., Setting: Injury and exposure data from 8 and 11 boys' and girls' rowing programs providing 13 and 17 team-seasons of data, respectively., Patients or Other Participants: High school boys' and girls' varsity rowing student-athletes., Intervention(s): High school rowing data from the National Athletic Treatment, Injury and Outcomes Network., Main Outcome Measure(s): Injury rates and rate ratios were reported with 95% confidence intervals (CIs)., Results: In HS boys' and girls' rowing, 59 and 190 injuries were reported, respectively, for rates of 2.39/1000 athlete-exposures (95% CI = 1.78, 3.00) and 8.60/1000 athlete-exposures (95% CI = 7.38, 9.82). The girls' rowing injury rate was 3.60 times that of boys' (95% CI = 2.69, 4.82)., Conclusions: These findings suggest a higher injury rate among HS female rowers than HS male rowers. Additional research exploring reasons for the sex difference is warranted.

Context: Anecdotal and qualitative evidence has suggested that some clinicians face pressure from coaches and other personnel in the athletic environment to prematurely return athletes to participation after a concussion. This type of pressure potentially can result in compromised patient care., Objective: To quantify the extent to which clinicians in the collegiate sports medicine environment experience pressure when caring for concussed athletes and whether this pressure varies by the supervisory structure of the institution's sports medicine department, the clinician's sex, and other factors., Design: Cross-sectional study., Setting: Web-based survey of National College Athletic Association member institutions., Patients or Other Participants: A total of 789 athletic trainers and 111 team physicians from 530 institutions., Main Outcome Measure(s): We asked participants whether they had experienced pressure from 3 stakeholder populations (other clinicians, coaches, athletes) to prematurely return athletes to participation after a concussion. Modifying variables that we assessed were the position (athletic trainer, physician) and sex of the clinicians, the supervisory structure of their institutions' sports medicine departments, and the division of competition in which their institutions participate., Results: We observed that 64.4% (n = 580) of responding clinicians reported having experienced pressure from athletes to prematurely clear them to return to participation after a concussion, and 53.7% (n = 483) reported having experienced this pressure from coaches. Only 6.6% (n = 59) reported having experienced pressure from other clinicians to prematurely clear an athlete to return to participation after a concussion. Clinicians reported greater pressure from coaches when their departments were under the supervisory purview of the athletic department rather than a medical institution. Female clinicians reported greater pressure from coaches than male clinicians did., Conclusions: Most clinicians reported experiencing pressure to prematurely return athletes to participation after a concussion. Identifying factors that are associated with variability in pressure on clinicians during concussion recovery can inform potential future strategies to reduce these pressures.