Community-Level Inequalities in Concussion Education of Youth Football Coaches

Protocol for COACH, an evidence-based intervention for improved head impact safety in youth American football developed using a community-engaged approach

Subconcussive, repetitive head impacts sustained in collision sports may negatively affect brain health. American football practices are controlled environments amenable to intervention. Engaging community members is essential for successful development, implementation, and sustainability of viable interventions. The objective of this study is to develop and pilot test an evidence-based intervention to reduce head impact exposure in youth American football (i.e., football), using a community-engaged approach. This manuscript describes the co-design of the intervention and associated implementation plan and the study protocol for evaluating the effectiveness and feasibility of the intervention and implementation plan. In the first part of this study, focus groups with parents and coaches, and individual interviews with organizational leaders associated with two teams at the middle school level were conducted. An anonymous survey assessing beliefs and perceptions of non-concussive head impacts was given to parents, coaches, and organizational leaders within the local youth football league. Following the football season, qualitative and quantitative data describing determinants of head acceleration events in football were shared with 12 stakeholders of coaches, league and school administrators, parents, an athletic trainer, and local university player development director. Together, we co-designed COACH (COmmunities Aligned to reduce Concussion and Head impact exposure) and implementation plan using a strategic planning approach. The preliminary effectiveness and feasibility were assessed in the second part of this study. Youth football players participating on the teams in year 1 (control teams) were fitted with mouthpiece-based head kinematic sensors which measure head acceleration events (HAEs). HAEs were collected and quantified during team activities. Preliminary effectiveness of the intervention to reduce HAEs was measured among two new teams pilot testing COACH with mouthpiece-based sensors, while simultaneously monitoring implementation of the intervention. We report our study design and evaluation, and opportunities and challenges with our approach. The results will inform a future full-scale pragmatic trial to assess the implementation and effectiveness of the intervention program. NCT04908930.

Does the Association Between Concussion Measures and Social Context Factors Differ in Black and White Parents?

CONTEXT

Middle school (MS) parents may benefit from education supporting timely concussion identification and care-seeking in their young children (aged approximately 10 to 15 years). However, such education may not consider individual needs and different social context factors, including lower socioeconomic status, disadvantaged social determinants of health, and different racial and ethnic backgrounds.

OBJECTIVES

To examine the relationship between social context factors and concussion knowledge, attitudes, and communication in MS parents and to explore the possible role of race and ethnicity (Black or White) as an effect measure modifier.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A nationally representative sample of MS parents who completed an online survey (n = 1248).

MAIN OUTCOME MEASURE(S)

Parent outcomes were a history of concussion education, concussion symptom knowledge and attitudes, and communication with children about concussion. Main exposures were parental race and ethnicity (Black or White) and social context factors. Uni- and multivariable statistical analyses were performed to achieve the study aims.

RESULTS

Black parents were more likely than White parents to have received concussion education (69.5% versus 60.5%, P = .009), although median concussion knowledge scores were higher for White parents than for Black parents (40 versus 37, P < .001). Few associations were found for social context factors with concussion knowledge, attitudes, and communication in Black and White parents separately.

CONCLUSIONS

Among MS parents, race and ethnicity may not influence the association between social context factors and concussion-related knowledge, attitudes, or communication. However, differences were present by race and ethnicity regarding previous concussion education and other parental outcomes, concussion symptom knowledge in particular.

Characterization of Head Acceleration Exposure During Youth Football Practice Drills

Many head acceleration events (HAEs) observed in youth football emanate from a practice environment. This study aimed to evaluate HAEs in youth football practice drills using a mouthpiece-based sensor, differentiating between inertial and direct HAEs. Head acceleration data were collected from athletes participating on 2 youth football teams (ages 11-13 y) using an instrumented mouthpiece-based sensor during all practice sessions in a single season. Video was recorded and analyzed to verify and assign HAEs to specific practice drill characteristics, including drill intensity, drill classification, and drill type. HAEs were quantified in terms of HAEs per athlete per minute and peak linear and rotational acceleration and rotational velocity. Mixed-effects models were used to evaluate the differences in kinematics, and generalized linear models were used to assess differences in HAE frequency between drill categories. A total of 3237 HAEs were verified and evaluated from 29 football athletes enrolled in this study. Head kinematics varied significantly between drill categorizations. HAEs collected at higher intensities resulted in significantly greater kinematics than lower-intensity drills. The results of this study add to the growing body of evidence informing evidence-based strategies to reduce head impact exposure and concussion risk in youth football practices.

Concussion education for youth athletes using Pre-Game Safety Huddles: a cluster-randomised controlled trial

OBJECTIVES

Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes.

METHODS

A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9-14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season.

RESULTS

Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen's d=0.35).

CONCLUSIONS AND RELEVANCE

Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting.

TRIAL REGISTRATION NUMBER

NCT04099329.

Concussion knowledge, attitudes, and norms: How do they relate?

BACKGROUND

Relationships between the constructs of concussion-related knowledge, attitudes, and norms and their influence on observed care-seeking behaviors have previously been examined. Current models posit that these constructs serve as potential mediators of care-seeking behaviors; however, the dynamics between them have yet to be reconciled.

METHODS

A cross-sectional, online survey explored relationships among the latent constructs of concussion-related knowledge, attitudes, and norms in parents of middle school children who participate in sports in multiple settings. A just-identified and two overidentified path models were explored and compared in an effort to understand such relationships.

RESULTS

A total of 426 parents of United States middle school students were surveyed and included in analyses (mean age = 38.7±9.9 years; 55.6% female; 51.4% white/non-Hispanic; 56.1% with at least a bachelor's degree). All parents had middle school aged children who participated in sport in both the club and school settings. The best fitting model was a just-identified model with concussion-related norms influencing concussion-related knowledge and attitudes, and concussion-related knowledge influencing attitudes. This model accounted for 14% of the variance in attitude and 12% of the variance in knowledge.

CONCLUSIONS

Study findings suggest that the constructs of concussion-related knowledge, attitudes and norms are directly related to one another, yet the dynamics of such relationships may be complex. As such, a parsimonious interpretation of these constructs may not be appropriate. Future research should work to further reconcile the dynamics between these constructs, and the impact these dynamics may have in influencing care-seeking behaviors beyond serving as mediators.

Use of sport-related concussion information sources among parents of United States middle school children

OBJECTIVE

Parents may use various information sources to obtain information about sport-related concussions (SRC). This study examined SRC-related information sources used by parents of United States middle school children (age: 10-15 years).

METHODS

A panel of 1083 randomly selected U.S. residents, aged ≥18 years and identifying as parents of middle school children, completed an online questionnaire capturing parental and child characteristics, and utilization and perceived trustworthiness of various sources of SRC-related information. Multivariable logistic regression models identified factors associated with utilizing each source. Adjusted odds ratios (OR) with 95% confidence intervals (95%CIs) excluding 1.00 were deemed significant.

RESULTS

Doctors/healthcare providers (49.9%) and other healthcare-related resources (e.g., Centers for Disease Control and Prevention, WebMD) (37.8%) were common SRC-related information sources; 64.0% of parents utilized ≥1 of these sources. Both sources were considered "very" or "extremely" trustworthy for SRC-related information among parents using these sources (doctors/healthcare providers: 89.8%; other healthcare-related resources: 70.9%). A 10-year increase in parental age was associated with higher odds of utilizing doctors/healthcare providers (adjusted odd ratio (OR_adjusted) = 1.09, 95%CI: 1.02-1.16) and other healthcare-related resources (OR_adjusted = 1.11, 95%CI: 1.03-1.19). The odds of utilizing doctors/healthcare providers (OR_adjusted = 0.58, 95%CI: 0.40-0.84) and other healthcare-related resources (OR_adjusted = 0.64, 95%CI: 0.44-0.93) were lower among parents whose middle school children had concussion histories versus the parents of children who did not have concussion histories.

CONCLUSION

One-third of parents did not report using doctors/healthcare providers or other healthcare-related resources for SRC-related information. Factors associated with underutilization of these sources may be targets for future intervention. Continuing education for healthcare providers and educational opportunities for parents should highlight accurate and up-to-date SRC-related information.

Sport concussion assessment in New Zealand high school rugby players: a collaborative approach to the challenges faced in primary care

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.

National Athletic Trainers' Association Position Statement: Reducing Intentional Head-First Contact Behavior in American Football Players

OBJECTIVE

To provide evidence-based recommendations for reducing the prevalence of head-first contact behavior in American football players with the aim of reducing the risk of head and neck injuries.

BACKGROUND

In American football, using the head as the point of contact is a persistent, well-documented, and direct cause of catastrophic head and cervical spine injury. Equally concerning is that repeated head-impact exposures are likely to result from head-first contact behavior and may be associated with long-term neurocognitive conditions such as dementia, depression, and chronic traumatic encephalopathy.

CONCLUSIONS

The National Athletic Trainers' Association proposes 14 recommendations to help the certified athletic trainer, allied health care provider, coach, player, parent, and broader community implement strategies for reducing the prevalence of head-first contact in American football.

Disparities and Inequities in Youth Sports

ABSTRACT

Participation in youth sports can have a positive, lasting impact on a child's general health and physical well-being. Unfortunately, some youth populations are unable to participate and/or reap the benefits of sports because of existing inequities. Youth from lower socioeconomic status and ethnic minority children have been found to participate in sports less. These disparities are unfortunately pervasive and likely the result of multiple barriers, including financial and time constraints, limited resources and the inability to access facilities both in and out of school, and lack of familial support. There also exist inequities with regard to sports injury management, including knowledge, access to athletic trainers, and care. This article provides a review of the numerous disparities and inequities in youth sports. Compiling and understanding these data may help develop a framework to make youth sports more equitable and beneficial for all.

Soccer, concussions, and safety: Perceptions of parents of youth soccer participants

INTRODUCTION

The rate of concussions in youth soccer is among the highest of all youth sports. Parents play an important role in caring for their children and making decisions regarding whether they should participate in a sport, such as soccer, where concussions are well known. This study examined parental perceptions regarding: (a) coaches' role in concussion management, (b) heading restriction policies, and (c) overall concussion risk and participation issues.

METHOD

Online surveys were completed by 419 parents of youth soccer players who participated in the largest U.S. youth soccer programs nationwide.

RESULTS

Findings indicated 44.5% of the respondents had considered keeping their children from playing organized soccer and 47.2% were concerned about a potential decline in youth soccer participation due to concussions. Nearly 69% of responding parents agreed that heading should be banned for participants 10 years old or younger, while 56.5% thought heading should not be limited for participants 13 or older. Only 35% of parents were very confident about their child's coach's ability to properly identify concussions and remove those suspected of a concussion from play. Parents' socioeconomic status (SES), soccer coaching and playing experience, and previous history of concussion(s) were key predictors of greater perceived risk about concussions.

CONCLUSIONS

Findings from this study shed light on parents' perceptions about concussions and related safety issues in youth soccer. Understanding what parents believe about concussions is vital to preserve youth soccer participation and can be used to strengthen education and policies that promote a safer environment for youth sport participants. Practical Applications: Youth soccer coaches can benefit from stronger, comprehensive educational efforts at the league/club level. Additionally, parents of youth athletes who are in the lower SES communities should be targeted to receive concussion safety information and/or interventions that would improve their knowledge, attitude, and practices regarding concussion safety.

Effect of Coach Feedback and Awareness of Head Impact Exposure on Practice Structure in Youth Football

With the concern of concussion risk and repetitive head impacts in youth football, organizations have adopted rules that limit contact during practice. However, rule changes are not ubiquitous among organizations and are challenging to monitor and enforce. Ultimately, football practice activities are determined by coaches, but it is unknown whether providing objective data to coaches relating activities to their athletes' head impact exposure (HIE) would alter practice structure or help reduce HIE. This study evaluated the effect of coach awareness of HIE on practice structure over time. Head impact data from three intervention (56 players) and three control (38 players) teams were collected over two youth football seasons. Athletes were instrumented with the Head Impact Telemetry (HIT) System and time-synchronized video was recorded for practices and games. Impact frequencies and head accelerations were compiled into weekly HIE practice and game reports and shared with the head coach of each intervention team. Time per drill, impact rate, and impact magnitude were compared across three time frames (pre-season, mid-season, and late-season) using generalized linear models. Control teams had higher impact rates than intervention teams in all drills across time frames. Among all teams, 95th percentile linear and rotational accelerations were highest during mid-season. Among intervention teams, more time was spent on scrimmage and skill development from pre-season to late-season, with less time spent on tackling. This study suggests that receiving objective data informing HIE in practice may contribute to changes in practice structure and help inform intervention efforts to improve head impact safety in football.

Assessing Differences in Concussion Symptom Knowledge and Sources of Information Among Black and White Collegiate-Athletes

OBJECTIVE

Basic concussion symptom knowledge is fundamental to concussion identification; however, racial disparities in concussion knowledge exist in high school and youth sports. It is unknown whether similar differences exist in collegiate-athletes. Identifying racial disparities in concussion knowledge and sources of concussion information is essential to inform equitable approaches to knowledge translation and educational interventions. This study examined how Black and White collegiate-athletes differed in their knowledge of concussion symptoms and use of concussion information sources.

SETTING

National Collegiate Athletic Association (NCAA) institutions.

PARTICIPANTS

Collegiate-athletes.

DESIGN

Cross-sectional.

MAIN MEASURES

Collegiate-athletes completed a questionnaire that assessed personal and sports demographics, concussion symptom knowledge, and use of concussion information sources. Fisher's exact tests and Wilcoxon rank-sum tests examined differences in outcome measures between Black and White collegiate-athletes. A multivariable Poisson regression model examined the association between race and concussion symptom knowledge scores while accounting for sex, sports contact level, NCAA division, concussion history, and specific concussion information sources. Incidence rate ratios (IRRs) with 95% CIs excluding 1.00 were deemed significant.

RESULTS

A total of 768 (82.6% White, 17.4% Black) collegiate-athletes completed the questionnaire. Black athletes were more likely to have lower concussion symptom knowledge scores than White athletes (P < .001). In the multivariable Poisson regression model controlling for covariates, this finding was retained (IRR = 0.97; 95% CI, 0.94-0.997). White athletes were more likely to report school-based professional (P < .001), online medical sources (P = .02), and the NCAA (P = .008) as sources of concussion information. Black athletes were more likely to report referees (P = .03) as a source of concussion knowledge.

CONCLUSION

Despite NCAA concussion education requirements for athletes, Black collegiate-athletes were found to have lower concussion knowledge than White collegiate-athletes. The findings highlight the need for equitable strategies to disseminate concussion information to diverse populations by improving the physician-patient relationship and investing in culturally appropriate educational materials.

Factors associated with concussion-symptom knowledge and attitudes toward concussion care seeking in a national survey of parents of middle-school children in the US

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.

Association Between Previous Concussion Education and Concussion Care-Seeking Outcomes Among National Collegiate Athletic Association Division I Student-Athletes

CONTEXT

Limited data exist concerning differences in concussion-education exposure and how education exposures relate to care seeking and symptom disclosure, specifically by National Collegiate Athletic Association Division I student-athletes.

OBJECTIVE

To investigate demographic characteristics associated with concussion-education exposure and examine whether overall education exposure (yes versus no) and education-source exposure number (multiple sources versus a single source) affect concussion care-seeking and disclosure factors in Division I student-athletes.

DESIGN

Cross-sectional study.

SETTING

Classroom or online survey.

PATIENTS OR OTHER PARTICIPANTS

Division I student-athletes (n = 341).

MAIN OUTCOME MEASURE(S)

Frequencies and proportions were computed for sex, race, school year, sport, and concussion history across concussion-education groups. Prevalence ratios (PRs) and 95% CIs were calculated to quantify the associations between student-athlete characteristics and (1) overall concussion-education exposure and (2) source-exposure number. Separate multivariable linear regression models estimated adjusted mean differences (MDs) and 95% CIs, which allowed us to assess differences in concussion knowledge, attitudes, and perceived social norms relative to concussion-education exposure and exposure to multiple sources. Separate multivariable binomial regression models were performed to estimate adjusted PRs and 95% CIs in order to evaluate associations of intention, perceived control, and care-seeking or disclosure behaviors and overall concussion-education exposure and exposure to multiple sources. All models controlled for sex, sport, and concussion history.

RESULTS

Overall, 276 (80.9%) participants reported previous concussion education, with 179 (64.9%) being exposed to multiple sources. Student-athletes who participated in a contact sport (adjusted PR = 1.24; 95% CI = 1.06, 1.44) and those who had a concussion history (adjusted PR = 1.19; 95% CI = 1.09, 1.31) had higher prevalences of concussion-education exposure. Females had a lower prevalence of reporting multiple sources (adjusted PR = 0.82; 95% CI = 0.68, 0.99). Overall concussion-education exposure was significantly associated with more favorable perceived social norms surrounding concussion care seeking (adjusted MD = 1.37; 95% CI = 0.13, 2.61).

CONCLUSIONS

These findings highlighted the potential differences in overall concussion-education exposure and provide clinicians with information on groups who may benefit from additional targeted education.

Fewer US Adolescents Playing Football and Public Health: A Review of Measures to Improve Safety and an Analysis of Gaps in the Literature

Physical activity during adolescence is associated with positive health outcomes, yet only 26% of US middle and high school students report daily physical activity. Moreover, the number of high school students playing a sport is declining, with the largest decline in football. One reason for this decline in playing football may be increased attention to the risk of head injury. For public health, the decline is alarming because football offers a physical activity opportunity for millions of young people every year. In response, efforts have been made to institute measures to enhance the safety of football. The objective of this topical review was to review these measures and the data supporting their effectiveness. We conducted a search of scientific literature supplemented by a web search to identify safety measures. We used the Indiana University library electronic database, PubMed, and web browser searches with specific search terms. In addition to peer-reviewed studies, we searched news stories and reports from sport-related organizations. We summarized the measures and evaluations of effectiveness and categorized the measures by type (game rules, practice guidelines, equipment innovations, strategic initiatives) and target age group (elementary/middle school, high school, college, professional). We found that attempts are being made to improve the safety of football at all levels. However, many measures lack scientific evidence to support their effectiveness. Therefore, researchers need to systematically evaluate safety measures. By implementing evidence-based interventions, we can balance the public health risk of playing football versus the public health risk of continued declines in participation.

Characteristics of Schools with Youth Sports Concussion-Related Educational Policies and Practices

BACKGROUND

School policies and practices designed to educate athletes, parents, and coaches about youth sports concussions may be a way to reduce concussion risk and improve both the recognition and management of concussions.

METHODS

Nationally representative data from the 2014 School Health Policies and Practices Study (SHPPS) were used to assess associations between school demographic characteristics (eg, school level, metropolitan status, and school type) and school policies and practices addressing youth sports concussion-related education for athletes, parents, and coaches.

RESULTS

Overall, many schools had policies and practices that addressed youth sports concussion-related education for athletes, parents, and coaches. There was significant variability in the adoption of policies and practices by some school demographic characteristics. Middle schools, private schools, and urban schools were less likely to adopt many of the policies and practices than high schools, public schools, and rural schools, respectively. For other school characteristics, no consistent patterns of associations emerged.

CONCLUSIONS

These findings suggest that middle, private, and urban schools, in particular, are more likely to lack youth sports concussion-related educational policies and practices and may need information or resources about the importance of education related to preventing, recognizing, and responding to concussions.

What they know and who they are telling: Concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players

The purpose of this study was to survey high school rugby players from a range of ethnic, geographic and socioeconomic backgrounds in New Zealand (NZ) to gain an understanding of concussion knowledge, awareness of NZ Rugby's (NZR) guidelines and attitudes towards reporting behaviours. Male and female high school rugby players (n= 416) from across NZ were surveyed. The findings indicated that 69% of players had sustained a suspected concussion, and 31% had received a medical diagnosis of concussion. 63% of players indicated they were aware of NZR's guidelines. Māori and Pasifika players were less likely to be aware of the guidelines compared to NZ European, Adjusted OR 0.5, p = 0.03. Guideline awareness was significantly higher for those from high decile schools when compared to low (Unadjusted OR 1.63, p = 0.04); however, when ethnicity and school locations were controlled for this became non-significant (Adjusted OR= 1.3, p=0.37). The coach was the key individual for the provision of concussion information and disclosure of symptoms for players. The findings of this study will inform the development and delivery of NZR's community concussion initiative and how these examined factors influence a high school player's concussion knowledge and reporting behaviour.

A New Game Plan for Concussion Education

Despite state laws requiring concussion education for youth sport stakeholders and a proliferation of educational programs, there has been little demonstrated impact on concussion reporting behaviors. We propose that this is because of four key limitations to existing approaches to concussion education: (1) deliberative decision making by the injured athlete is assumed, (2) interventions are often targeted at individuals rather than social systems, (3) education occurs once during preseason and is forgotten, and (4) dissemination challenges exacerbate health inequalities. Addressing these limitations, we propose a novel theoretic framework that situates individual behavior within a sport system's culture and their broader structural context. Concussion education programs should seek to facilitate safety-supportive interpersonal communication within and between stakeholder groups and influence attributes of groups that drive behavior, including shared values. Addressing the limitations outlined and drawing on the proposed conceptual framework, we describe a novel approach to concussion education: pregame safety huddles.

The influence of behavioural and socioeconomic factors on the community injury rates of adolescents assessed by the south Korean emergency medical services: an ecological approach

Background

Aim of this study is to determine if peer group risk behaviors and neighbourhood socioeconomic status (SES) would ecologically affect injury incidence according to place and gender among adolescents (aged 13–15) in South Korea.

Methods

Three variables from the Korea Youth Risk Behavior Survey (2014) were used to represent peer group risk behaviours; current alcohol consumption (cAlc), the experience of violence or bullying (VicVB), and having undergone education for injury prevention (Edu-IP). The Korea Census Data (2010) was used for neighborhood SES; the degree of urbanization, the proportion of high educational attainment, and the proportion of low residential environment. The nationwide and regional Incidence-Rates of Injury assessed by EMS (IRI-EMS) were calculated according to age and gender based on the number of injuries from EMS record (2014). A linear regression model was used to examine associations.

Results

The nationwide total and inside-school IRI-EMS were 623.8 and 139.3 per 100,000 population, respectively. The range of the regional IRI-EMS showed a maximum of about 4 times the difference from 345 to 1281 per 100,000 population depending on the region. The low residential environment had a significant effect on the increase of total IRI-EMS (β = 7.5, 95% CI 0.78–14.21). In the case of boys, the IRI-EMS inside-school was increased as the percentage of VicVB was higher (β = 17.0, 95% CI 1.09–32.91). In the case of girls, the IRI-EMS outside-school was increased in rural compared to urban location (β = 211.3, 95% CI 19.12–403.57).

Conclusion

The incidence rate of outside-school was higher than that of inside-school, and incidence rate of boys was higher than that of girls. Peer group risk behaviors were significant only in the injury of boys. Among the SES factors, rural area was a significant factor in girls, especially outside-school injury. Moreover, the rate of households not in an apartment was significant in all outside-school injury and outside-school injury of boys.

Our study suggests that among native South Korean adolescents, neighbourhood SES and peer group risk behavior have different effects depending on the injury context such as place of occurrence or gender.

A technology-enabled electronic incident report to document and facilitate management of sport concussion: A cohort study of youth and young adults

Despite the widespread awareness of concussion across all levels of sport, the management of concussion from youth to college is inconsistent and fragmented. A fundamental gap contributing to inconsistent care is the lack of a scalable, systematic approach to document initial injury characteristics following concussion. The purpose of this study was to determine differences in injury profiles and management of youth, high school, and college athletes using a mobile application for incident report documentation.A cohort study was conducted in which concussion electronic incident report data from 46 high schools and colleges, and Cleveland Clinic ambulatory concussion clinics were gathered and analyzed.In sum, 1421 (N = 88 youth, N = 1171 high school and N = 162 college) athletes with sport-related concussions were included.Despite the relative absence of red flags, youth athletes had a greater probability of being sent to the emergency department than high school and collegiate athletes. Over 60% of athletes were removed from play immediately post-injury. Injury recognition was delayed in 25% of athletes due to delayed symptom reporting (20% of males, 16% of females) or delayed symptom onset (5% of males, 9% of females). A significantly greater incidence of red flags was evident in males, and in high school and collegiate athletes compared to youth athletes.The high frequency of youth athletes sent to the emergency department, despite the absence of red flags, may be a reflection of inadequate medical coverage at youth events, ultimately resulting in unnecessary utilization of emergency medicine services. The relatively high incidence of delayed injury reporting implies that additional educational efforts targeting student-athletes and the utilization of resources to improve injury detection are warranted. The systematic collection of injury-related demographics through the electronic mobile application facilitated interdisciplinary communication and improved the efficiency of managing athletes with concussion.

Comparison of head impact exposure in practice drills among multiple youth football teams

Objective

Limiting contact in football practice can reduce the number of head impacts a player receives, but further research is needed to inform the modification of optimal drills that mitigate head impact exposure (HIE) while the player develops the skills needed to safely play the game. This study aimed to compare HIE in practice drills among 6 youth football teams and to evaluate the effect of a team on HIE.

Methods

On-field head impact data were collected from athletes (ages 10–13 years) playing on 6 local youth football teams (teams A–F) during all practices using the Head Impact Telemetry System. Video was recorded and analyzed to verify and assign impacts to a specific drill. Drills were identified as follows: dummy/sled tackling, half install, install, install walk through, multiplayer tackle, Oklahoma, one-on-one, open field tackling, other, passing, position skill work, scrimmage, special teams, tackling drill stations, and technique. HIE was quantified in terms of impacts per player per minute (ppm) and peak linear and rotational head acceleration. Generalized linear models were used to assess differences in head impact magnitude and frequency among drills as well as among teams within the most common drills.

Results

Among 67 athlete-seasons, a total of 14,718 impacts during contact practices were collected and evaluated in this study. Among all 6 teams, the mean linear (p < 0.0001) and rotational (p < 0.0001) acceleration varied significantly among all drills. Open field tackling had significantly (p < 0.001) higher mean linear acceleration than all other drills. Multiplayer tackle had the highest mean impact rate (0.35 ppm). Significant variations in linear acceleration and impact rate were observed among teams within specific drills. Team A had the highest mean linear acceleration in install, one-on-one, and open field tackling and the highest mean impact rate in Oklahoma and position skill work. Although team A spent the greatest proportion of their practice on minimal- or no-player versus player contact drills (27%) compared to other teams, they had the highest median (20.2g) and 95th percentile (56.4g) linear acceleration in practice.

Conclusions

Full-speed tackling and blocking drills resulted in the highest HIE. Reducing time spent on contact drills relative to minimal or no contact drills may not lower overall HIE. Instead, interventions such as reducing the speed of players engaged in contact, correcting tackling technique, and progressing to contact may reduce HIE more effectively.

The Epidemiology of Injuries in Middle School Football, 2015-2017: The Advancing Healthcare Initiatives for Underserved Students Project

BACKGROUND

Although data exist on injuries in youth football leagues, there are limited recent data on injury incidence in middle school football. Updated injury incidence estimates can help drive the development of injury prevention strategies.

PURPOSE

Describe the epidemiology of injuries in middle school football during school years 2015-2016 to 2017-2018.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Data originated from 9 public middle schools in Virginia during school years 2015-2016 to 2017-2018. Certified athletic trainers collected injury and athlete-exposure (AE) data from school-sanctioned games and practices in boys', football. Injury counts and rates per 1000 AEs were calculated. Injury rate ratios with 95% CIs compared rates between games and practices.

RESULTS

Overall, 664 middle school boys', football injuries were reported, leading to an overall injury rate of 20.54 per 1000 AEs (95% CI, 18.98-22.11). The time loss injury rate (inclusive of injuries with participation restriction time ≥24 hours) was 9.28 per 1000 AEs (95% CI, 8.23-10.33). The injury rate was higher in competition than practice (36.19 vs 17.97 per 1000 AEs; injury rate ratio, 2.01; 95% CI, 1.69-2.40). Most injuries were to the head/face (competition, 20.6%; practice, 15.8%) and hand/wrist (competition, 18.8%; practice, 16.4%) and were diagnosed as contusions (competition, 30.9%; practice, 25.9%) and sprains (competition, 19.4%; practice, 12.6%). Competitions also had a large proportion of concussions (10.3%). Overall, 80.0% and 66.9% of injuries were due to contact in competition and practice, respectively; of these contact-related injuries, 62.1% and 41.6% were specifically player contact.

CONCLUSION

Injury distributions parallel those found in previous research from middle school and other sport settings. Injury rates in middle school football were higher than those reported in previous findings in high school and college. However, caution must be taken when interpreting findings in relation to other surveillance systems with varying methodologies. Still, the findings highlight the need for injury prevention strategies within middle school football, particularly as related to contact-related mechanisms.

Using opinion leaders to address intervention gaps in concussion prevention in youth sports: key concepts and foundational theory

Behavioral interventions to increase disclosure and proper management of concussion in youth sports have unrealized potential when it comes to preventing concussion. Interventions have focused on changing individual athlete behavior and have fallen short of the potential for sustained systemic behavioral change. One potentially critical reason for this shortfall is that other key determinants of risk behaviors at all levels of the socio-ecological model (e.g. interpersonal, community, policy) are not addressed in extant programming. There is a critical need for theory-driven interventions that address concussion prevention and education at the community level and target sustainable culture change. The Popular Opinion Leader (POL) intervention, a multi-level intervention model previously successfully employed in multiple public health contexts, is theoretically well positioned to affect such change. POL is based on the Diffusion of Innovations framework and involves identifying, recruiting, and training well-respected and trusted individuals to personally endorse prevention and risk-reduction within their social networks. Critical behavioral changes related to concussion disclosure and management have been shown to diffuse to others if enough opinion leaders endorse and support the behaviors. This article summarizes the concepts and principles of POL and describes how it could be adapted for and implemented in youth sport settings. For optimal impact, POL needs to adapt to several factors unique to youth sports settings and culture. First, adult involvement may be important, given their direct involvement in the athlete's medical care. However, parents and coaches' opinions on injury care-seeking, competition, and safety may affect their perceptions of POL. Second, youth sports are structured settings both physically and socioculturally. Games and practices may provide opportunities for the informal interactions that are critical to the success of POL. However, youth sport setting membership is transient as players get older and move to other sport settings; POL approaches need to be self-sustaining despite this turnover. Moreover, stakeholder value placed on athlete development and competition, alongside safety, must be considered. Formative research is needed to ensure that POL principles are translated into the youth sport setting while maintaining fidelity to the concepts and principles that have made POL successful for other health outcomes.