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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.

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.)

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.)

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.

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.

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.