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

Exercise has been shown to reduce fatigue in early breast cancer survivors (EBCS), though it is unclear if these results translate to community-based exercise settings. Mechanisms that influence changes in fatigue seen after exercise are also poorly understood. This study sought to evaluate the impact of community-based exercise and identify associations of fatigue in EBCS.Twenty-nine EBCS and 13 non-cancer controls (CON) enrolled. Pre/post-intervention measurements included measures of fitness/function, balance, and adherence/compliance as well as self-reported measures of fatigue, health-related quality of life (HRQOL), well-being, self-efficacy, and physical activity. Both groups participated in a supervised 16-week aerobic + resistance exercise intervention. A mixed model ANOVA and Cohen's D effect size assessed fatigue changes, and univariable linear regressions identified fatigue associations.Fatigue improved for EBCS (- 2.6, Cohen's D = 0.51) but not CON (0.0, Cohen's D = 0.02); no interaction effect was observed. Post-intervention fatigue in EBCS was associated with better QOL (RCommunity-based exercise appears beneficial for alleviating fatigue in EBCS. These improvements may be driven by parallel improvements in psychosocial outcomes and objectively measured functional outcomes.

Studies have observed variable associations of prior contact sport participation with subjective and objective measures of cognitive function. This study directly investigated the association between subjective self-report and objective performance-based cognition among former collegiate football players, as well as its relationship to self-reported concussion history.Former collegiate football players (N = 57; mean age = 37.9 years [Subjective cognition was not significantly associated with any objective measures of cognitive functioning (Reliance on self-reported measures of cognitive functioning alone is insufficient when assessing cognition in former contact sport athletes. Assessment of other factors known to influence subjective cognitive complaints should also be examined in determining the presence of cognitive deficits.

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

Context Lower extremity osteoarthritis (OA) is associated with a 25% greater risk of cardiovascular disease (CVD) compared to those without OA. The prevalence of traumatic joint injuries among National Football League (NFL) players exposes these athletes to an elevated risk for osteoarthritis (OA) and potentially a greater risk of cardiovascular risk factors (CRF) and CVD. Objective To examine the association between a history of lower extremity joint injury, lower extremity OA, and the prevalence of CRFs and CVD among former NFL athletes. Design Cross Sectional Study Patients or Other Participants Former NFL players completed a health questionnaire. A sub-sample of 1,738 former players reported lifetime medical diagnoses including CVD or CRFs. Main Outcome Measure(s) Crude and adjusted prevalence ratios (PR) characterized the association between CVD or CRF with injury and/or OA diagnosis among athletes who reported 1) no history of lower extremity joint injury or surgery and no diagnosed OA, 2) athletes with a history of lower extremity joint injury or surgery and no OA diagnosed OA, and 3) athletes with a history of lower extremity joint injury or surgery and diagnosed OA. Results Neither history of lower extremity joint injury (PRadj=1.34, CI95=0.86, 2.07) nor history of lower extremity joint injury and diagnosed OA (PRadj=1.41, CI95=0.89, 2.25) were significantly associated with CVD. However, CRFs were 30% and 53% more prevalent in former players with lower extremity joint injury and no diagnosed OA (PRadj=1.30, CI95=1.12, 1.50) and those with lower extremity joint and diagnosed OA (PRadj=1.53, CI95=1.31, 1.78) when compared to athletes with no history of either condition. Conclusions The prevalence of CRFs was highest among former NFL athletes with a history of lower extremity joint injury and diagnosed OA. These findings provide insight regarding the potential pathways to chronic diseases that may be initiated by joint injury early in life.

BACKGROUND Potential links between a history of sport-related concussions and later-life neurobiological and psychological brain health have been studied in former collision-sport athletes. However, empirical studies of how former athletes perceive the future of their brain health as a result of these injuries are missing. OBJECTIVES We aimed to (1) identify the extent to which former National Football League players currently have concerns about their long-term psychological and cognitive functioning as a result of concussions sustained while playing football; (2) examine whether current concerns are different than concerns they had while playing football; (3) examine the relationship between current brain health concerns and self-reported concussion history (SR-CHx); and (4) explore other important factors associated with these concerns. METHODS In this cross-sectional study, former National Football League players with a SR-CHx of one or more concussions (n = 1514; aged mean [standard deviation] = 52.3 [15.7] years) completed a general health questionnaire. Participants reported their lifetime concussion history, as well as both their current concerns and concerns while playing football (i.e., retrospective concerns) regarding the long-term effects of concussions on their memory, thinking skills, and risk of developing chronic traumatic encephalopathy. Current and retrospective concerns were self-reported on a five-point Likert scale. Four concussion history categories were created based on SR-CHx: 1-2 (n = 309); 3-5 (n = 413); 6-9 (n = 356); and 10 + (n = 436) lifetime concussions. Proportions of participants reporting each level of current and retrospective concerns were examined to identify whether concerns presently exist in these former players, and whether their current concerns are different than retrospective concerns. Next, we explored associations between current concerns and SR-CHx. RESULTS More than one-third of participants reported being currently "extremely concerned" about memory problems (36.9%), thinking skills (37.8%), and developing chronic traumatic encephalopathy (39.5%). In contrast, when asked about concerns while playing, most reported being "not at all concerned" regarding memory = 61.2%, thinking skills = 56.1%, and developing chronic traumatic encephalopathy = 71.2%. Of those who retrospectively endorsed being "not at all" or "slightly" concerned regarding memory (n = 1159/1514), thinking skills (n = 1080/1514), and developing chronic traumatic encephalopathy (n = 1219/1514), approximately half reported being currently "moderately" or "extremely" concerned about those same issues (n = 586/1159; n = 534/1080; n = 619/1219, respectively). Current concerns regarding memory (χ216 = 316.61; p

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

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

PURPOSE This study examined worker characteristics and behaviors, and the perceived importance of job-related tasks associated with the willingness to perform a proposed probation officer physical ability test (PROPAT). METHODS North Carolina probation officers (N = 1,213; 46.2% female; 39.8 ± 10.1 years; 30.7 ± 6.6 kg/m2) completed a survey including demographics, health history, and job-related tasks. A multivariable logistic regression model estimated the odds of being willing to perform the PROPAT. Adjusted odds ratios (ORadjusted) with 95% confidence intervals (CI) were calculated, with those excluding 1.00 deemed statistically significant. RESULTS The majority (72%) of probation officers were willing to perform the PROPAT. Being male (compared to female) (ORadjusted = 1.50; 95%CI = 1.12-2.02), having moderate (ORadjusted = 1.51; 95%CI = 1.10-2.08) and high physical activity status (ORadjusted = 2.89; 95%CI = 1.97-4.28) (compared to low) increased the odds of being willing to perform the PROPAT. Additionally, reporting a greater importance of tasks including running to pursue a suspect (TASKRUN; 1-unit-increase; ORadjusted = 1.25; 95%CI = 1.10-1.43) and dragging an unresisting person (TASKDRAG; 1-unit-increase; ORadjusted = 1.16; 95%CI = 1.01-1.32) increased the odds of being willing to perform the PROPAT. Increasing age (1-year increase; ORadjusted = 0.96; 95% CI = 0.94-0.98), class II (ORadjusted = 0.45; 95%CI = 0.28-0.71) and class III obesity (compared to normal weight; ORadjusted = 0.55; 95% CI = 0.32-0.93), and a previous musculoskeletal injury (ORadjusted = 0.57; 95%CI = 0.35-0.93) all decreased the odds of being willing to perform the PROPAT. CONCLUSIONS These results suggest being older, previously injured, obese (BMI ≥ 35 kg/m2), and less active is associated with being less willing to participate in the PROPAT, while males and reporting a higher importance of the TASKRUN and TASKDRAG activities is associated with being more willing to participate in the PROPAT. Departments can use these findings to identify feasible strategies (e.g., education, physical training) to improve the implementation of physical employment standards.

The COVID-19 pandemic has resulted in changes to the structure of sport and the experiences of athletes. In this commentary, we consider how these changes, including schedule disruptions and the early termination of careers, have contributed to a reconsideration of how athlete transition should be defined, examined, and intervened upon. We outline our rationale for this proposed reconfiguration, including implications for researchers and practitioners working with athletes during the COVID-19 pandemic and beyond. For researchers, we recommend updating the transition definition, reconsidering the measurement of salient transition-related variables, and utilizing study designs/methods that best facilitate this work. For practitioners, we recommend considering the dynamic nature of transition within holistic athlete care, building momentum on mental health destigmatization achieved during the pandemic, athlete transition education, and clinician advocacy for transition-related resources for athletes. Ultimately, we hope this work will spark continued innovations in athlete transition research and practice moving forward.

Background Literature examining emergency medical services (EMS) activations for sport-related injuries is limited to the pediatric, high school, and collegiate student-athlete populations, excluding older individuals and recreational athletes. The purpose of this study was to examine EMS activations for sport-related injuries using the National EMS Information System Database from 2017-2018. Methods Data were obtained using the National EMS Information System Database from 2017-2018. EMS activations were limited to 9-1-1 responses for individuals aged 3-99 who sustained a sports-related injury. Independent variables included patient age group: pediatric (18 years old) vs. adult (≥18 years old). Dependent variables were patient age, gender, and chief complaint anatomic location. Frequencies and proportions were calculated for each variable. Injury proportion ratios (IPRs) with 95% confidence intervals were calculated to compare chief complaint anatomic location by age group. Results There were 71,322 sport-related injuries. Patients were 36.6±22.9 years and most (58.1%, n=41,132) were male. Adults had higher proportions of injuries affecting the abdomen (IPR: 2.05, 95%CI: 1.83, 2.31), chest (IPR: 1.90, 95%CI: 1.75, 2.05), general/global (IPR: 1.54, 95%CI: 1.50, 1.58), and genitalia (IPR: 2.40, 95%CI: 1.39, 4.15), and lower proportions of injuries affecting the back (IPR: 0.55, 95%CI: 0.50, 0.60), lower extremity (IPR: 0.63, 95%CI: 0.60, 0.65), upper extremity (IPR: 0.50, 95%CI: 0.47, 0.53), head (IPR: 0.73, 95%CI: 0.70, 0.77), and neck (IPR: 0.18, 95%CI: 0.16, 0.20) compared to pediatric patients. Conclusion Injuries sustained differed between adult and pediatric patients, indicating sport-related emergencies may change across the lifespan. General/global chief complaints likely indicate sport-related injuries affecting multiple anatomic locations and organ systems. Stakeholders planning large or high-risk athletic events should consider arranging standby or dedicated advanced life support units for their events.

Context Limited research exists concerning the relationship between the social determinants of health (SDOHs), including race, socioeconomic status (SES), health care access and physical environment and concussion nondisclosure in collegiate athletes. However, among high school athletes, disparities have been noted, with Black athletes who attended under-resourced schools and lacked access to an athletic trainer (AT) disclosing fewer concussions. Objective To investigate whether concussion nondisclosure disparities existed by (1) race, (2) SES, or (3) AT health care access before college and understand the differential reasons for concussion nondisclosure between White and Black collegiate athletes. Design Cross-sectional study. Setting Collegiate athletics. Participants A total of 735 college athletes (84.6% White, 15.4% Black). Main Outcome Measure(s) Participants completed a questionnaire that directly assessed concussion nondisclosure, including reasons for not reporting a suspected concussion. With the premise of investigating SDOHs, race was the primary exposure of interest. The outcome of interest, nondisclosure, was assessed with a binary (yes or no) question, “Have you ever sustained a concussion that you did not report to your coach, AT, parent, teammate, or anyone else?” Results Among the White and Black athletes, 15.6% and 17.7%, respectively, reported a history of concussion nondisclosure. No differences were found by race for distributions of history of concussion nondisclosure (P = .57). Race was not associated with concussion nondisclosure when evaluated as an effect modification measure or confounder, and no significant associations were noted by SES or high school AT access. Differences by race for reported reasons for nondisclosure were present for “At the time, I did not think it was a concussion” (P = .045) and “I thought my teammates would think I am weak” (P = .03), with Black athletes selecting these more frequently than White athletes. Conclusions These data help to contextualize race and its intersection with other SDOHs that could influence concussion nondisclosure outcomes in collegiate athletes.

Context The National Federation of State High School Associations previously implemented 2 lacrosse rule modifications: Rule 5.4 in the 2012–2013 academic year to heighten the penalty for a head or neck hit to the head, face, or neck (HFN) and Rule 5.3.5 in the 2013–2014 academic year to minimize body checking. Objective To determine if the rates of overall injury, HFN injuries, and concussions due to intentional contact (checking) differed for boys' high school lacrosse players after Rule 5.4 and 5.3.5 modifications were enacted. Design Descriptive epidemiology study. Setting Web-based online surveillance system. Patients or Other Participants Boys' high school lacrosse players during the 2008–2009 to 2016–2017 seasons whose teams involved athletic trainers participating in the High School Reporting Information Online sports injury-surveillance system. Intervention(s) Rule 5.4 in the 2012–2013 academic year increased the penalty for any intentional hits to the HFN, and Rule 5.3.5 in the 2013–2014 year eliminated body checking to a player in a defenseless position. Main Outcome Measure(s) Overall, HFN, and concussion injury rate ratios (IRRs) by checking mechanism; overall and checking-related injury ratios by competitions and practices. Results A decrease was shown in checking-related HFN injuries (IRR = 0.29, 95% CI = 0.13, 0.65) and checking-related concussions (IRR = 0.29, 95% CI = 0.12, 0.70) during practices in the seasons after both rule modifications were imposed, but no decreases occurred in any checking-related injuries during competitions. By injury mechanism, no decreases were evident after the Rule 5.4 modification. When both rule modifications (Rules 5.4 and 5.3.5) were enacted together, concussion rates due to delivering body checks (IRR = 0.51, 95% CI = 0.29, 0.91) and overall injury risk due to being body checked (IRR = 0.72, 95% CI = 0.53, 0.97) decreased. Conclusions When both Rule 5.4 and 5.3.5 modifications were in effect, concussion and overall injury risks decreased for the body checker and the player being body checked, respectively.

The purpose of this study was to investigate the effects of sport participation, concussion history, and age of first exposure to football on preseason cerebrovascular function in adolescent athletes. Athletes (n = 53, age = 15.8 ± 1.2 years) were examined based on three exposure groupings: (1) sport participation (football vs. non-collision), (2) concussion history (none vs. ≥ 1), and (3) age of first exposure (football participants only). Transcranial Doppler assessed cerebrovascular reactivity (CVR) and neurovascular coupling (NVC), and separate independent samples t-tests evaluated group differences in CVR and NVC outcomes. Separate univariate linear regressions determined how age of first exposure related to CVR and NVC outcomes. Linear mixed effects models assessed group differences in CVR and NVC relative response curves. Differential response to NVC visual task response was significantly greater in non-collision sport athletes (F1,2946 = 38.69, p < 0.0001) and athletes without a concussion history (F1,2946 = 25.23, p < 0.0001). Older age of first exposure significantly predicted reduced breath-holding CVR response (F1,1560 = 2.92, p = 0.03). Healthy adolescent athletes have similar pre-season cerebrovascular function despite different sport participation and concussion history. However, age of first exposure may predict CVR in adolescent football athletes. Developmental literature identifies cerebrovascular function as dynamically changing throughout adolescence. Our study provides fundamental data informing the clinical meaningfulness of short- and long-term physiological function changes.

Highlights • Middle school parents’ concussion-symptom knowledge scores were relatively high; however, parents struggled to identify emotional symptoms, such as feeling sadness, being more emotional, and feeling nervous or anxious, as concussion symptoms. • Parents generally had positive attitudes toward concussion care seeking, although they noted some difficulty in the perceived ease of seeking concussion care. • Numerous factors were found to be associated with greater concussion-symptom knowledge and more positive concussion care-seeking attitudes. For example, the odds of higher scores were associated with increased parental age and with being white or non-Hispanic vs. being from another racial or ethnic group., Background Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents’ general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion-symptom knowledge and care-seeking attitudes among parents of MS children (aged 10–15 years). Methods A panel of 1224 randomly selected U.S. residents, aged ≥ 18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents’ concussion-symptom knowledge was measured using 25 questions, with possible answers being “yes”, “maybe”, and “no”. Correct answers earned 2 points, “maybe” answers earned 1 point, and incorrect answers earned 0 point (range: 0–50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range: 5–35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) (excluding 1.00) were deemed statistically significant. Results Median scores were 39 (interquartile range: 32–44) for symptom knowledge and 32 (interquartile range: 28–35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71–3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42–2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26–1.71), and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13–1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06–1.99) and in older parental age (10-year-increase aOR = 1.24; 95%CI: 1.05–1.47). Conclusion Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion-symptom knowledge and care-seeking attitudes. Parents’ variations in concussion knowledge and attitudes warrant tailored concussion education and prevention., Graphical abstract Image, graphical abstract

Context Exertional heat stroke (EHS) deaths can be prevented by adhering to best practices. Objective To investigate high schools' adoption of policies and procedures for recognizing and treating patients with EHS and the factors influencing the adoption of a comprehensive policy. Design Cross-sectional study. Setting Online questionnaire. Patients or Other Participants Athletic trainers (ATs) practicing in the high school (HS) setting. Main Outcome Measure(s) Using the National Athletic Trainers' Association position statement on exertional heat illness, we developed an online questionnaire and distributed it to ATs to ascertain their schools' current written policies for using rectal temperature and cold-water immersion. The precaution adoption process model allowed for responses to be presented across the various health behavior stages (unaware if have the policy, unaware of the need for the policy, unengaged, undecided, decided not to act, decided to act, acting, and maintaining). Additional questions addressed perceptions of facilitators and barriers. Data are presented as proportions. Results A total of 531 ATs completed the questionnaire. Overall, 16.9% (n = 62) reported adoption of all components for the proper recognition and treatment of EHS. The component with the highest adoption level was “cool first, transport second”; 74.1% (n = 110) of ATs described acting on or maintaining the policy. The most variability in the precaution adoption process model responses was for a rectal temperature policy; 28.7% (n = 103) of ATs stated they decided not to act and 20.1% (n = 72) stated they maintained the policy. The most frequently cited facilitator of and barrier to obtaining rectal temperature were a mandate from the state HS athletics association (n = 274, 51.5%) and resistance to or apprehension of parents or legal guardians (n = 311, 58.5%), respectively. Conclusions Athletic trainers in the HS setting appeared to be struggling to adopt a comprehensive EHS strategy, with rectal temperature continuing as the biggest challenge. Tailored strategies based on health behavior, facilitators, and barriers may aid in changing this paradigm.

Highlights • Uniforms were integrated over time, but once integrated were not removed when hotter environmental conditions occurred. • Players in the age-restricted league were taller, heavier, and had a higher BMI than players in the weight-restricted league, resulting in significant anthropometric differences. • Work time was significantly greater for games, as were rest times. However, work-to-rest ratios were significantly higher for practices. • Of the practices and games observed 9% were held in black flag risk conditions and 68% were held in red flag conditions. • One league's average WBGT during games was significantly higher than the other because of the time of day they were held (9:00 a.m. to 2:00 p.m.). • More than 50% of players reached a gastrointestinal temperature of 39°C or higher at least once during the observation, but no players reached a TG1 indicative of exertional heat stroke., Objective To determine which intrinsic and extrinsic exertional heat illness (EHI) risk factors exist in youth American football players and observe perceptual and physiological responses of players during events (games and practices). Methods Cross-sectional cohort study observing 63 youth football players, varying in position. Independent variables were league (weight-restricted (WR, n = 27) and age-restricted (AR, n = 36)) and event type. Dependent variables were anthropometrics, work-to-rest ratio, and wet bulb globe temperature. Descriptive variables included preparticipation examination and uniform configuration. A subset of 16 players participated in physiological variables (heart rate and gastrointestinal temperature). Data collection occurred on 7 AR and 8 WR nonconsecutive practices and the first 3 games of the season. Results Mean values for anthropometric variables were higher (p < 0.05) in the AR league than the WR league. Work time (χ2 (1,111) = 4.232; p = 0.039) and rest time (χ2 (1,111) = 43.41; p < 0.001) were significantly greater for games, but ratios were significantly higher for practices (χ2 (1,111) = 40.62; p < 0.001). The majority of events (77%) observed were in black and red flag wet bulb globe temperature risk categories. A total of 57% of the players had a preparticipation examination, and up to 82% of events observed were in full uniforms. Individual gastrointestinal temperature and heart rate responses ranged widely and no players reached critical thresholds. Conclusion Extrinsic (disproportionate work ratios, environmental conditions) and intrinsic (higher body mass index) EHI risk factors exist in youth football. Certain risk factors may be influenced by event and league type. National youth football organizations need to create thorough guidelines that address EHI risk factors for local leagues to adopt., Graphical Abstract Image, graphical abstract

Clinicians often use symptom cluster presentations to inform concussion diagnosis and provision of care. The current review appraises the analytical methods used for the identification of clinically meaningful clusters based on symptom assessments. Symptom clustering was commonly examined in relation to scores calculated using established assessment instruments. The majority of studies utilized Factor Analysis techniques for examining clustering, although statistical analyses were heterogeneously described by authors. Other techniques employed included time series network models, and cluster analysis using the joining tree method. While there exists strong evidence to suggest multidimensionality in symptom presentations, the analytical foundations of these conclusions warrant further consideration. Future work in reconciling the underlying structure of symptom presentations may consider the nuances of the data captured using symptom assessment instruments, and the applicational limitations of commonly utilized data reduction techniques. Techniques that accommodate temporal dynamics of symptom presentations also warrant exploration in conducting this work.

Context Although it has been suggested that developmental and sociological factors play a role in concussion reporting, the empirical evidence related to this is limited. Objective To examine the influences of sex, school level, school location, concussion-reporting history, and socioeconomic status on concussion-related knowledge, attitudes, and reporting intentions among middle school and high school athletes. Design Cross-sectional study. Setting Middle School students and High School athletes attending pre-participation examinations (PPEs) were asked to complete paper-based surveys. Patients or Other Participants Overall, 541 athletes representing 18 sports returned fully completed surveys. Main Outcome Measure(s) Outcomes were concussion-related knowledge, perceived seriousness, positive feelings about reporting, and self-reporting intentions. We examined group differences in these outcomes across levels of the explanatory variables of sex, school level (middle school versus high school), school location (urban versus rural), concussion self-reporting history (yes or no), and socioeconomic status (free or reduced-price lunch versus no free or reduced-price lunch) using Wilcoxon rank sum tests. Then we used multivariable ordinal logistic regression models to identify predictors of higher score levels for each outcome. Odds ratio (OR) estimates with 95% confidence intervals (CIs) excluding 1.00 were deemed significant. Results Odds of higher levels of knowledge were higher in urban versus rural school student-athletes (ORAdjusted = 1.81; 95% CI = 1.03, 3.17), and lower in student-athletes on free or reduced-price lunch versus those not on free or reduced-price lunch (ORAdjusted = 0.52; 95% CI = 0.36, 0.77). Similarly, odds of higher levels of seriousness were lower in male versus female student-athletes (ORAdjusted = 0.48; 95% CI = 0.32, 0.72). Further, odds of higher levels of self-reporting intentions were lower among male versus female student-athletes (ORAdjusted = 0.53; 95% CI = 0.37, 0.75). Conclusions Developmental and sociological factors were differentially associated with concussion-related knowledge, attitudes, and self-reporting intentions. These results can inform medical providers, parents, and coaches with regard to context-specific clinical assessments of concussion symptoms.

The aim of this study was to evaluate New Zealand high school rugby union players’ and community coaches’ concussion knowledge (CK), concussion attitude (CA) and concussion reporting intentions (CRI) and to explore the impact gender, age, ethnicity, socio-economic status, experience, and concussion history had on these outcome measures. This cross-sectional study utilised the Rosenbaum Concussion Knowledge and Attitudes survey to evaluate CK, CA and CRI. The survey and demographic information were completed by 533 high school players (61.5% male, M = 16.2 yrs) and 733 community rugby coaches (93.0% male, M = 42.2 yrs). Coaches displayed greater awareness, safer attitudes, and stronger reporting intentions towards concussion than players. Among players, differences in CK, CA and CRI were observed by gender, ethnicity, and socio-economic status. Among coaches, differences in CRI were found by age and coaching experience. No differences were observed for age or concussion history in players. Gender, ethnicity, and grade coached were not significant for coaches. Players who identified as Māori or Pasifika and those from schools in low socio-economic areas displayed poorer CK and CA. Years of experience for both players and coaches played a critical role in improving CA and is a factor that should be considered when welcoming new participants to either role. Concussion non-disclosure is a systemic issue and is common across gender, ethnicity and socio-economic status and appears to worsen as the playing season progresses. More work is needed to develop educational strategies that are both culturally responsive, sustainable, and address reporting behaviours.

Context Athletic trainers (ATs) are educated and trained in appropriate exertional heat-stroke (EHS) management strategies, yet disparities may exist between intended and actual uses in clinical practice. Objective To examine the intended and actual uses of EHS management strategies among those who did and those who did not treat patients with suspected cases of EHS during the 2017 high school (HS) American football preseason. Design Cross-sectional study. Setting Online questionnaire. Patients or Other Participants A total of 1016 ATs who oversaw patient care during the 2017 HS American football preseason. Main Outcome Measure(s) Responding HS ATs recorded whether they had or had not managed patients with suspected EHS events during the 2017 HS American football preseason. Those who had managed patients with suspected cases of EHS reported the management strategies used; those who had not managed such patients described their intended management strategies. For each management strategy, z tests compared the proportions of actual use among ATs who managed patients with suspected EHS with the proportions of intended use among ATs who did not manage such patients. Results Overall, 124 (12.2%) ATs treated patients with suspected EHS cases during the 2017 HS American football preseason. Generally, the proportions of intended use of management strategies among ATs who did not treat patients with suspected EHS were higher than the actual use of those strategies among ATs who did. For example, ATs who did treat patients with suspected EHS were more likely than those who did not treat such patients to intend to take rectal temperature (19.6% versus 3.2%, P < .001) and immerse the athlete in ice water (90.1% versus 51.6%, P < .001). Conclusions Inconsistencies occurred between intended and actual use of EHS management strategies. The standard of care for managing patients with suspected cases of EHS was not consistently used in clinical practice, although ATs who did not treat EHS stated they intended to use these management strategies more frequently. Future researchers should identify factors that preclude ATs from using the standard of care when treating patients with suspected cases of EHS.

Context Emergency action plans (EAPs) are a critical component in the management of catastrophic sport-related injury. Some state high school athletics associations and state legislation have required that schools develop EAPs, but little research exists on the influence of a statewide policy requirement on local adoption of these policies. Objective To examine the efficacy of a statewide policy requirement on local adoption of an EAP. Design Cross-sectional study. Setting Online questionnaire. Patients or Other Participants Secondary school athletic trainers were invited to complete a survey (n = 9642); 1136 completed the survey, yielding an 11.7% response rate. Main Outcome Measure(s) Survey responses on the adoption of EAPs along with cardiopulmonary resuscitation and automated external defibrillator (CPR/AED) requirements were cross-referenced with published statewide policies to determine the prevalence of EAP adoption. We evaluated the adoption of emergency action plan components based on the National Athletic Trainers' Association's emergency planning position statement along with CPR/AED requirements to determine component-specific prevalence. We compared the prevalence of EAP and component adoption between states that required EAPs and specific components of EAPs and states without such requirements. Results Athletic trainers in states that required adoption of an EAP reported including more components of the emergency planning position statement (mean = 8 ± 4, median = 9) than in states without a requirement (mean = 7 ± 4, median = 8). The adoption of EAP components did not differ between states that required specific components of the EAP versus development of the EAP only. However, schools in states with both EAP and CPR/AED training requirements reported higher rates of CPR/AED training implementation (95.5%) than states that only required CPR/AED training (81.6%, prevalence ratio = 1.10, 95% confidence interval = 1.01, 1.20). Conclusions Based on these data, statewide policy requirements for the development of an EAP may be associated with increasing adoption of EAPs.

Context: Recent data on exertional heat illness (EHI) in high school sports are limited yet warranted to identify specific settings with the highest risk of EHI. Objective: To describe the epidemiology of EHI in high school sports during the 2012/2013–2016/2017 academic years. Design: Descriptive epidemiology study. Setting: Aggregate injury and exposure data collected from athletic trainers working in high school sports in the United States. Patients or Other Participants: High school athletes during the 2012/2013–2016/2017 academic years. Intervention: High School Reporting Information Online surveillance system data from the 2012/2013–2016/2017 academic years were analyzed. Main Outcome Measures: EHI counts, rates per 10,000 athlete exposures (AEs), and distributions were examined by sport, event type, and US census region. EHI management strategies provided by athletic trainers were analyzed. Injury rate ratios with 95% confidence intervals (CIs) compared EHI rates. Results: Overall, 300 EHIs were reported for an overall rate of 0.13/10,000 AE (95% CI, 0.11 to 0.14). Of these, 44.3% occurred in American football preseason practices; 20.7% occurred in American football preseason practices with a registered air temperature ≥90°F and ≥1 hour into practice. The EHI rate was higher in American football than all other sports (0.52 vs 0.04/10,000 AE; injury rate ratio = 11.87; 95% CI, 9.22 to 15.27). However, girls’ cross-country had the highest competition EHI rate (1.18/10,000 AE). The EHI rate was higher in the South US census region than all other US census regions (0.23 vs 0.08/10,000 AE; injury rate ratio = 2.96; 95% CI, 2.35 to 3.74). Common EHI management strategies included having medical staff on-site at the onset of EHI (92.7%), removing athlete from play (85.0%), and giving athlete fluids via the mouth (77.7%). Conclusions: American football continues to have the highest overall EHI rate although the high competition EHI rate in girls’ cross-country merits additional examination. Regional differences in EHI incidence, coupled with sport-specific variations in management, may highlight the need for region- and sport-specific EHI prevention guidelines.

Timely disclosure and identification of concussion symptoms are essential to proper care. Perceived social norms are a potential driving factor in many health-related decisions. The study purpose was to describe concussion disclosure behaviours and identify the association between perceived social norms and these disclosure behaviours. First-year student-athletes (n = 391) at two NCAA institutions completed a cross-sectional survey about concussion disclosure and disclosure determinants. Log-binomial regression models identified factors associated with concussion disclosure behaviour prevalence for: higher intention to disclose symptoms, disclosed all at time of injury, eventually disclosed all, and never participated with concussion symptoms. More favourable perceived social norms were associated with higher prevalence of intention to disclose (PR = 1.34; 95%CI: 1.18, 1.53) and higher prevalence of never participating in sports with concussion symptoms (PR = 1.50; 95%CI: 1.07, 2.10). Clinicians, coaches, sports administrators, and healthcare practitioners should be mindful of the need to create supportive social environments to improve concussion symptom disclosure.

Continued monitoring of ankle sprain rates and distributions is needed to assess temporal patterns and gauge how changes in incidence may be associated with prevention efforts.Describe the epidemiology of ankle sprains in 15 high school sports during the 2011/12-2018/19 school years.Descriptive epidemiology study.Online injury surveillance from high school sports.High school athletes who participated in practices and competitions during the 2011/12-2018/19 school years.A convenience sample of high school athletic trainers (ATs) provided injury and athlete-exposure (AE) data to the National High School Sports-Related Injury Surveillance Study (HS RIOTM). Ankle sprain rates per 10,000AE with 95% confidence intervals (CI) and distributions were calculated. Yearly rates were examined overall, by event type, injury mechanism, and recurrence.Overall, 9,320 ankle sprains were reported (overall rate=2.95/10,000AE; 95%CI: 2.89-3.01). The highest sport-specific rates were reported in girls' basketball (5.32/10,000AE), boys' basketball (5.13/10,000AE), girls' soccer (4.96/10,000AE), and boys' football (4.55/10,000AE). Most ankle sprains occurred during competition (54.3%) and were due to contact with another person (39.5%) and non-contact (35.0%). Also, 14.5% of injuries were noted as recurrent. Across the included academic years, ankle sprain rates generally increased. Compared to the 2011/12 academic year, rates in the 2018/19 academic year overall were 22% higher; non-contact-related and recurrent ankle sprain rates also generally increased, with 91% and 29% increases, respectively.Time trends suggest ankle sprain rates have increased across the past decade, particularly among those with non-contact-related mechanisms; this contrasts previous research suggesting decreases in incidence. Findings may pinpoint specific etiological factors that should direct prevention efforts. This includes considering both person-contact and non-contact mechanisms through mitigating illegal contact through rule changes and enforcement, alongside bracing and proprioceptive and balance training programs.

Background: Beneficial 24-hour activity behaviors (i.e., limiting sedentary behavior, physical activity, sleep) are critical for chronic disease prevention, but were altered by the COVID-19 pandemic. Less time in beneficial 24-hour activity behaviors may place individuals at greater risk for contracting COVID-19. Further, some populations may be more impacted than others, with demographic and environmental (rural/urban/suburban) factors influencing access to healthcare and COVID-19 information. Methods: In December 2020, we recruited an online convenience sample of 746 adults aged 18 years or older residing in the US. Of the sample, 400 (39±14 years old, 52% female, 15% Hispanic, 78% White, and 28% had or survived cancer) had complete data for our variables of interest. Participants self-reported demographic information, COVID-19 diagnosis (yes/no), total weekday and weekend sedentary behavior (hours/day), moderate to vigorous physical activity (mins per week), sleep (hours/day), and environment (rural/urban/suburban). a) A k-fold cross-validation, machine learning variable selection (glmnet) approach was used to identify which variables were most strongly associated with COVID-19 prevalence, as determined by specifying the tuning parameter, λ, at its minimum value. This approach minimizes the elastic net penalty and optimizes the model fit. b) Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (95%CI) for the strongly associated variables. Results: a) The variables most associated with COVID-19 prevalence were total sedentary behavior during weekdays, sleep, biological sex, race, and environment (λ=0.012). b) Holding all other parameters constant, the odds of having COVID-19 were lower for every additional hour of sleep (OR=0.87, 95%CI=0.79, 0.96); identifying as non-white versus white (OR=0.46, 95%CI=0.23, 0.87); living in a rural versus urban area (OR=0.42, 95%CI=0.18, 0.92); and higher for being male versus female (OR=2.79, 95%CI=1.69, 4.67). Non-significant decreases were found for weekday sedentary behavior (OR=0.97; 95%CI=0.92, 1.02) and living in a suburban versus urban areas (OR=0.63, 95%CI=0.38, 1.05). Conclusion: Less sleep, identifying as non-white, female, and residing in rural areas were associated with a lower COVID-19 prevalence.

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.

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

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

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

Objective To report pre-season baseline concussion assessment performance among senior rugby players and explore associations between assessment performance and player demographics. Design A cross-sectional study using the New Zealand Rugby Concussion Assessments (NZRCA), comprising symptom, cognitive and dynamic coordination assessments was conducted in the 2018-2019 season. Methods Players' baseline assessments were characterised using descriptive statistics; effect sizes (ES) and t-tests were used to explore associations between player demographic characteristics and NZRCA performance. Results A total of 733 players (11.4% female) aged between 16 and 52 years completed the NZRCA. The median (range) value for symptom severity, endorsed symptoms and "percentage normal" was respectively, 5 (0-40), 5 (0-21) and 90% (30-100%). A perfect standardised assessment of concussion score was achieved by one participant; seven achieved ≥27/30 for immediate recall, and 22 achieved a perfect delayed recall score. Most participants (n = 674, 92%) passed the tandem gait test. Associations between NZRCA performance and gender, concussion history, and Pasifika ethnicity were observed with effect sizes ranging from small (0.18) to large (0.70). Six hundred and twenty-three (85%) participants reported at least one symptom. Conclusions The results from this study could help support decision-making by clinicians, improving the management of concussions in the community setting.

Background: Injury incidence for physically active populations with a high volume of physical load can exceed 79%. There is little existing research focused on timing of injury and how that timing differs based on certain risk factors. Purpose/Hypothesis: The purpose of this study was to report both the incidence and timing of lower extremity injuries during cadet basic training. We hypothesized that women, those with a history of injury, and those in underweight and obese body mass index (BMI) categories would sustain lower extremity musculoskeletal injury earlier in the training period than men, those without injury history, and those in the normal-weight BMI category. Study Design: Cohort study; Level of evidence, 2. Methods: Cadets from the class of 2022, arriving in 2018, served as the study population. Baseline information on sex and injury history was collected via questionnaire, and BMI was calculated from height and weight taken during week 1 at the United States Military Academy. Categories were underweight (BMI Results: A total of 595 cadets participated. The cohort was 76.8% male, with 29.9% reporting previous injury history and 93.3% having a BMI between 20 and 30. Overall, 16.3% of cadets (12.3% of male cadets and 29.7% of female cadets) experienced an injury during the follow-up period. Women experienced significantly greater incident injury than did men ( P < .001). Separation of survival curves comparing the sexes and injury history occurred at weeks 3 and 4, respectively. Hazards for first musculoskeletal injury were significantly greater for women versus men (HR, 2.63; 95% CI, 1.76-3.94) and for those who reported a history of injury versus no injury history (HR, 1.76; 95% CI, 1.18-2.64). No differences were observed between BMI categories. Conclusion: Female cadets and those reporting previous musculoskeletal injury demonstrated a greater hazard of musculoskeletal injury during cadet basic training. This study did not observe an association between BMI and injury.