Disparities in Athletic Trainer Staffing in Secondary School Sport: Implications for Concussion Identification

Knowledge, attitude and behaviour around concussion at the FIFA Women's World Cup 2023: part 2 - coaches, performance staff and players

The objective of this observational cross-sectional study was to assess the knowledge, attitude and behaviour of coaches and performance staff (i.e. 'coaching staff'), and players from the 32 teams qualified for the FIFA Women's World Cup 2023 regarding assessment and management of concussion in football. Two online surveys were developed: 1) coaching staff, and 2) players. The results were analysed descriptively. Eighty-four coaching staff and 229 players completed the survey. Concussion knowledge: 39% of coaching staff and 33% of players were aware of concussion protocol(s). Knowledge: concussion symptom onset time was correctly reported by 18% of coaching staff and 11% of players. Knowledge about risks related to sustaining a concussion or returning to play too soon varied in both groups. Attitude: 26% of coaching staff and 31% of players reported being very confident or confident in recognizing a suspected concussion. Half of the players (52%) reported to always report symptoms of concussion if feeling any. One (1%) member of the coaching staff and 24 (10%) players reported feeling that a player can return to play with mild symptoms after a concussion. Behaviour: Most coaching staff reported they would have supportive behaviour if faced with a suspected concussion on the pitch. Among players, 64% stated that they would leave the assessment to their team's medical staff, and 4% would encourage their teammates to keep playing. In conclusion, coaching staff and players showed limited knowledge about concussion. Most coaching staff reported attitudes and intended behaviour towards protecting players' health; whilst players' responses varied.

Optimizing Concussion Care Seeking: Using Machine Learning to Predict Delayed Concussion Reporting

BACKGROUND

Early medical attention after concussion may minimize symptom duration and burden; however, many concussions are undiagnosed or have a delay in diagnosis after injury. Many concussion symptoms (eg, headache, dizziness) are not visible, meaning that early identification is often contingent on individuals reporting their injury to medical staff. A fundamental understanding of the types and levels of factors that explain when concussions are reported can help identify promising directions for intervention.

PURPOSE

To identify individual and institutional factors that predict immediate (vs delayed) injury reporting.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study was a secondary analysis of data from the Concussion Assessment, Research and Education (CARE) Consortium study. The sample included 3213 collegiate athletes and military service academy cadets who were diagnosed with a concussion during the study period. Participants were from 27 civilian institutions and 3 military institutions in the United States. Machine learning techniques were used to build models predicting who would report an injury immediately after a concussive event (measured by an athletic trainer denoting the injury as being reported "immediately" or "at a delay"), including both individual athlete/cadet and institutional characteristics.

RESULTS

In the sample as a whole, combining individual factors enabled prediction of reporting immediacy, with mean accuracies between 55.8% and 62.6%, depending on classifier type and sample subset; adding institutional factors improved reporting prediction accuracies by 1 to 6 percentage points. At the individual level, injury-related altered mental status and loss of consciousness were most predictive of immediate reporting, which may be the result of observable signs leading to the injury report being externally mediated. At the institutional level, important attributes included athletic department annual revenue and ratio of athletes to athletic trainers.

CONCLUSION

Further study is needed on the pathways through which institutional decisions about resource allocation, including decisions about sports medicine staffing, may contribute to reporting immediacy. More broadly, the relatively low accuracy of the machine learning models tested suggests the importance of continued expansion in how reporting is understood and facilitated.

Racial and Ethnic Diversity of Athletic Trainers in National Collegiate Athletic Association Institutions, 2008-2018: A Retrospective Study

CONTEXT

Athletic trainers (ATs) are the most visible members of the sports medicine team and are responsible for the health and well-being of student-athletes. However, the representation of Black, Indigenous, and people of color (BIPOC) ATs in National Collegiate Athletic Association (NCAA) member institutions has not been studied.

OBJECTIVE

To quantify the representation of BIPOC ATs in National Collegiate Athletic Association (NCAA) member institutions.

DESIGN

Cross-sectional study.

SETTING

National Collegiate Athletic Association's Demographic Database.

PATIENTS OR OTHER PARTICIPANTS

Team athletic personnel at NCAA member institutions.

MAIN OUTCOME MEASURE(S)

Chi-square tests were used to assess differences in racial and ethnic frequencies across division, calendar year, and gender. Linear regression models were calculated to examine changes in racial and ethnic distributions of head and assistant ATs over time.

RESULTS

Most NCAA ATs were categorized as White (88%), which was reflected in both head (90.8%) and assistant (87.2%) AT positions. Black ATs made up the largest proportion of a specific racial or ethnicity group within BIPOC ATs (3.4% of head ATs, 4.6% of assistant ATs), with the next most prevalent being Hispanic (2.8% of head ATs, 3.9% of assistant ATs). Historically Black Colleges and Universities showed higher proportions of BIPOC ATs in both the head and assistant categories than non-historically Black institutions. Division I schools had the greatest AT racial or ethnicity diversity in comparison with Divisions II and III (P < .0001). In our linear regression models, we found increases in many of the racial or ethnic categories for both head and assistant ATs.

CONCLUSIONS

We demonstrated that BIPOC ATs represented a small proportion of the ATs currently working at NCAA member institutions. Although BIPOC ATs have increased over the past 10 years, a large racial and ethnic discordance gap still exists between student-athletes and the ATs caring for them.

Sport-related concussion attitudes and knowledge in elite English female footballers

BACKGROUND

Sport-related concussions (SRC) are more common and more severe in women's football than men's yet the knowledge and attitudes of SRC in the women's game are not well understood. The objective of this study was to assess the SRC knowledge and attitude in elite female footballers.

METHODS

An online questionnaire was sent to all registered players in the English Football Association Women's Super League (WSL) and Championship. Respondents completed an amended version of the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS). Concussion Knowledge Index (CKI) and Concussion Attitudes Index (CAI) scores were derived for all respondents.

RESULTS

One hundred and twenty-three players completed the survey with 111 fitting the inclusion criteria. The mean CKI score was 20.5 ± 2.3 and the mean CAI score was 63.3 ± 6.3. A weak positive correlation was shown between the CKI and CAI (r = 0.20; p = 0.03). Previous concussion education had a significant impact on increased knowledge (U = 1198; p = 0.04). There was no significant difference in concussion attitudes and knowledge between the WSL and Championship or in those with a previous concussion history and no previous concussion (p > 0.05).

CONCLUSION

Previous SRC education demonstrated an increased knowledge around concussion but a limited impact towards concussion attitudes. It is suggested that concussion education should be mandated across the professional game to enhance player welfare.

Acute Sport-Related Concussion Management and Return to Sport Time in High School Athletes

BACKGROUND

The current evidence for acute management practices of sport-related concussion (SRC) is often limited to in-clinic visits, with limited studies identifying professionals in early SRC care and the association with prolonged recovery outcomes.

PURPOSE

To describe acute SRC management practices (ie, the personnel in the initial evaluations, removal from activity) and test the association with prolonged return to sport (RTS) time.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We conducted a retrospective cohort study of 17,081 high school SRCs accrued between the 2015-2016 and 2020-2021 academic years. We reported acute management practices and RTS time as frequencies stratified by sex, sport, and event type and compared athletic trainer (AT) access in initial evaluation with chi-square tests (P < .05). Separate logistic regressions estimated odds ratios (ORs) and 95% CIs for removal from activity and prolonged RTS >21 days by acute management practices.

RESULTS

Most SRCs (n = 12,311 [72.1%]) had complete initial evaluation by an AT. Boys had an AT evaluation in 75.5% (n = 2860/3787) of practice-related and 74.8% (n = 5551/7423) of competition-related events. Girls had an AT evaluation in 61.3% (n = 1294/2110) of practice-related and 69.3% (n = 2606/3761) of competition-related events. In sex-comparable sports (n = 6501), there was no difference between boys (n = 1654/2455 [67.4%]) and girls (n = 2779/4046 [68.7%]) having an AT involved in the first evaluation (χ2 = 1.21; P = .27). Notably, 25.3% of girls' SRCs were evaluated by a coach alone, and we observed differences in personnel in initial evaluations by sport. The odds of immediate removal were higher when an AT made the initial evaluation (OR, 2.8 [95% CI, 2.54-3.08]). The odds of prolonged RTS >21 days was lower for those with an AT in the initial evaluation (OR, 0.74 [95% CI, 0.65-0.84]) adjusting for significant factors from univariate analyses, boys relative to girls (OR, 0.85 [95% CI, 0.76-0.96]), specialty care relative to PCP (OR, 2.16 [95% CI, 1.90-2.46]), specialty care relative to urgent or ready care (OR, 0.99 [95% CI, 0.82-1.22]) concussion history (OR, 1.41 [95% CI, 1.22-1.63]), and removal from activity (OR, 0.90 [95% CI, 0.78-1.05]).

CONCLUSION

This study found variability in personnel involved in initial SRC evaluations, with higher percentages of athletes with SRCs having ATs make the initial evaluation during competitive events. There was no association between sex and AT involvement in comparable sports. There was an association between prolonged RTS and AT involvement, sex, concussion history, and location of follow-up care.

Focus areas and methodological characteristics of North American-based health disparity research in sports medicine: a scoping review

OBJECTIVE

Health disparities are widely prevalent; however, little has been done to examine and address their causes and effects in sports and exercise medicine (SEM). We aimed to summarise the focus areas and methodology used for existing North American health disparity research in SEM and to identify gaps in the evidence base.

DESIGN

Scoping review.

DATA SOURCES

Systematic literature search of PubMed, Scopus, SPORTDiscus, CINAHL Plus with Full Text, Web of Science Core Collection and Cochrane Central Register of Controlled Trials.

ELIGIBILITY CRITERIA

Full-text, peer-reviewed manuscripts of primary research, conducted in North America; published in the year 2000 or after, in English; and focusing on organised sports were included.

RESULTS

103 articles met inclusion criteria. Articles were classified into five focus areas: access to and participation in sports (n=45), access to SEM care (n=28), health-related outcomes in SEM (n=24), provider representation in SEM (n=5) and methodology (n=1). Race/ethnicity (n=39), socioeconomic status (n=28) and sex (n=27) were the most studied potential causes of health disparities, whereas sexual orientation (n=5), location (rural/urban/suburban, n=5), education level (n=5), body composition (n=5), gender identity (n=4) and language (n=2) were the least studied. Most articles (n=74) were cross-sectional, conducted on youth (n=55) and originated in the USA (n=90).

CONCLUSION

Health disparity research relevant to SEM in North America is limited. The overall volume and breadth of research required to identify patterns in a heterogeneous sports landscape, which can then be used to inform positive change, need expansion. Intentional research focused on assessing the intersectionality, causes and consequences of health disparities in SEM is necessary.

Stunt performers' reluctance to self-report head trauma: a qualitative study

BACKGROUND

Mild traumatic brain injuries receive voluminous attention in the research literature, but this is confined almost entirely to sports and military contexts. As an occupation, performing stunts in film, television, and entertainment places the head at high risk of repetitive impact and whiplash, but stunt performers do not enjoy the same level of healthcare supervision and access as that provided to sports participants. Therefore, the aim of this study was to evaluate stunt performers' qualitative perceptions of reporting and management of head trauma in their industry.

METHODS

After giving their informed consent, 87 motion picture and television stunt performers responded to a query about their views of ways to improve how stunt performers' occupational head trauma-specifically head impacts and head whips that could cause a concussion-are reported and managed. We analyzed their responses via content and thematic analyses. Two researchers independently marked and categorized key words, phrases, and texts to identify codes that described participants' comments. They then revised, discussed, and resolved coding discrepancies through consensus to establish inter-coder reliability. Next, we identified thematic patterns that described participants' understanding of the stunt performer industry and what must change to facilitate reporting of head trauma. We derived themes from data that occurred multiple times, both within and across short answer responses.

RESULTS

We identified three primary themes cited by the stunt performers as needs in their industry: (1) Need to Reduce the Stigma of Reporting a Stunt-Related Injury, (2) Need to Eliminate the "Cowboy Culture," and (3) Need to Improve the Quality of the Work Environment.

CONCLUSIONS

Stunt performers are crucial members of a global entertainment industry valued at approximately US$100 billion annually. A large segment of the world's population consumes their work in motion pictures, television, and live entertainment. When they are given an anonymous opportunity to speak, stunt performers offer insight into and recommendations for industry changes-primarily cultural and educational in nature-that could improve their physical and mental health, career longevity, and employability when they are confronted with head trauma.

Factors That May Influence Americans' Views on When Children Should Start Playing Tackle Football

CONTEXT

American football is associated with the largest number of emergency department visits for pediatric sport-related traumatic brain injury, including concussions. Tackling is responsible for almost two-thirds of football concussions. Some have recommended implementing age restrictions on tackling in youth football.

OBJECTIVE

To determine whether the public would support age restrictions and the factors that may drive such support.

DESIGN

Cross-sectional study.

SETTING

Summer wave of Porter Novelli's 2020 US ConsumerStyles survey.

PARTICIPANTS

A total of 4053 adults.

MAIN OUTCOME MEASURE(S)

Respondents answered questions about a good age for children to start playing tackle football, past football playing history, concerns about safety, and the benefits and risks of playing football.

RESULTS

Most respondents believed that middle (32.8%) or high (27.8%) school was a good age to start playing tackle football. About 1 in 5 (19.8%) respondents reported that children should never play tackle football. Certain groups of individuals were more likely to support children starting to play tackle football at high school age or above or to say that they should never play tackle football, including those with a bachelor's degree or higher (rate ratio [RR]HS+ = 1.41, 95% CI = 1.14, 1.76; RRNEVER = 2.70, 95% CI = 1.93, 3.78), those who did not have children under 18 (RRHS+ = 1.54, 95% CI = 1.26, 1.90; RRNEVER = 1.54, 95% CI = 1.14, 2.07), those who were not football fans (RRNEVER = 3.07, 95% CI = 2.32, 4.06), and those who were very (RRHS+ = 3.94, 95% CI = 2.87, 5.42; RRNEVER = 11.52, 95% CI = 7.32, 18.15) or somewhat (RRHS+ = 1.88, 95% CI = 1.41, 2.52) concerned about the safety of children.

CONCLUSION

Despite acknowledging the benefits of playing football, many adults expressed concern about safety and endorsed high school age and older or never as a good age to start playing tackle football, highlighting a disconnect with current football program practices regarding age.

Intersection of Race and Socioeconomic Status on Concussion Recovery among NCAA Student-Athletes: A CARE Consortium Study

PURPOSE

The objectives of this study are to 1) describe collegiate student-athlete (SA) race and household income and 2) evaluate time to normal academic performance (i.e., return to learn (RTL)), initiation of the return to play (iRTP) protocol, RTP protocol duration, and time to unrestricted RTP (URTP) after sustaining sport-related concussion (SRC).

METHODS

Data were collected between 2014 and 2020 by the Concussion Assessment, Research, and Education Consortium. Baseline data were used to characterize participant demographics ( N = 22,819) and post-SRC outcomes ( n = 5485 SRC) in time to RTL ( n = 1724) and RTP outcomes ( n = 2646) by race. Descriptive statistics and nonparametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox proportional hazards regression assessed the effect of race on risk of RTL and RTP recovery time points.

RESULTS

SA largely identified as White (75%) followed by Black (14%), multiracial (7%), and Asian (3%). More than half (53%) of all SA reported a household income of >$120,000, whereas 41% of Black SA reported a household income <$60,000. Race was not associated with relative risk of RTL or iRTP but was associated with RTP protocol completion and URTP. Non-Black/non-White SA were 17% less likely (adjusted hazard ratio = 0.83; 95% confidence interval = 0.71, 0.97) to complete the RTP protocol, and Black SA were 17% more likely (adjusted hazard ratio = 1.17; 95% confidence interval = 1.05, 1.31) to reach the URTP time point compared with White SA.

CONCLUSIONS

The present findings suggest collegiate SA enrolled in the Concussion Assessment, Research, and Education Consortium are primarily White and come from household incomes well above the US median. Race was not associated with RTL or iRTP but was associated with RTP protocol duration and total time to URTP. Clinicians should be conscientious of how their implicit or preconceived biases may influence SRC management among National Collegiate Athletic Association SA.

Provision of Concussion Information From Coaches and the Presence of Athletic Trainers: Findings From the 2021 YouthStyles Survey

Coaches play an important role in concussion safety, and their views on concussion influence those of their athletes and the athletes' reporting behaviors. In this 2021 survey of youth, we examined how often coaches provide concussion safety information to their athletes and the association between coaches' provision of concussion information to athletes and the presence of athletic trainers (ATs) at a team's games and practices. More than 4 in 10 youth who played sports reported that their coaches did not provide any sort of concussion education or information to them in the past 12 months. Among those youth who always or sometimes had ATs at practices or games, 76.3% received some type of coach education on concussion in the past 12 months, compared with 31.9% of those who rarely or never had ATs at practices or games (P < .0001). Increasing access to ATs and adapting current concussion training and educational materials for coaches to increase coach-athlete communication may be beneficial.

Group Differences in Postconcussion Cognitive, Physical, Sleep-Arousal, and Affective Symptom Subscales in High School and Collegiate Athletes by Race, Gender, and Competitive Level

OBJECTIVE

Prior psychometric research has identified symptom subscales for the Post-Concussion Symptom Scale (PCSS) based on confirmatory factor analysis (CFA), including cognitive, physical, sleep-arousal, and affective symptom factors. Study objectives included: (1) replicate the 4-factor PCSS model in a diverse sample of athletes with concussion, (2) test the model for invariance across race, gender, and competitive level, and (3) compare symptom subscale and total symptom scores across concussed groups with established invariance.

SETTING

Three regional concussion care centers.

PARTICIPANTS

A total of 400 athletes who completed the PCSS within 21 days of concussion (64% boys/men, 35% Black, and 69.5% collegiate athletes).

DESIGN

Cross-sectional.

MAIN MEASURES

A CFA tested the 4-factor model and measurement invariance testing was performed across racial, competitive level, and gender groups. Symptom subscales and total symptom severity scores were compared based on demographic groupings with established invariance.

RESULTS

The 4-factor model fit well and strong invariance was established across all demographic categories, indicating symptom subscales could be meaningfully compared across groups. Black and White athletes differed on total symptoms (U = 15 714.5, P = .021, r = 0.12), sleep-arousal symptoms (U = 15 953.5, P = .026, r = 0.11), and physical symptoms (U = 16 140, P = .051, r = 0.10), with Black athletes reporting slightly more symptoms. Collegiate athletes reported greater total symptom severity (U = 10 748.5, P < .001, r = 0.30), with greater symptom reporting on the cognitive (U = 12 985, P < .001, r = 0.21), sleep-arousal (U = 12 594, P < .001, r = 0.22), physical (U = 10 959, P < .001, r = 0.29), and emotional (U = 14 727.5, P = .005, r = 0.14) symptom subscales. There were no significant differences by gender in the total symptom score or subscale scores. After controlling for time since injury, no racial differences persisted, but a significant difference by competitive level in physical symptom reporting (F = 7.39, P = .00, η2 = 0.02) and total symptom reporting (F = 9.16, P = .003, η2 = 0.02) remained.

CONCLUSION

These results provide external validation for the PCSS 4-factor model and demonstrate that symptom subscale measurements are comparable across race, genders, and competitive levels. These findings support the continued use of the PCSS and 4-factor model for assessing a diverse population of concussed athletes.

Return-to-learn after concussion in Washington state public high schools during the COVID-19 pandemic

Aim: To understand academic support structures for Washington state public high school students with concussion during the COVID-19 pandemic. Materials & methods: Prospective, repeated cross-sectional study of 21 schools in 2020 and 2021. Results: About 28% of schools reported not providing any return-to-learn (RTL) accommodations for students with concussion throughout the COVID-19 pandemic. RTL accommodation provision was associated with larger student body size ( β = 0.002) and higher graduation rate ( β = 0.261) but was not associated with presence of RTL school policy. About 38.1% of schools received no guidance on how to provide RTL accommodations during the COVID-19 pandemic, and many reported that students with concussion struggled more. Conclusion: Schools struggled to provide RTL accommodations for students with concussion during the COVID-19 pandemic, highlighting the need for evidence-based guidance and resource allocation to vulnerable schools.

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.

Differences in Access to Athletic Trainers in Public Secondary Schools Based on Socioeconomic Status

CONTEXT

Significant health care disparities exist in the United States based on socioeconomic status (SES), but the role SES has in secondary school athletes' access to athletic training services has not been examined on a national scale.

OBJECTIVE

To identify differences in access to athletic training services in public secondary schools based on school SES.

DESIGN

Cross-sectional study.

SETTING

Database secondary analysis.

PATIENTS OR OTHER PARTICIPANTS

Data for 3482 public high schools.

MAIN OUTCOME MEASURE(S)

Data were gathered from the Athletic Training Locations and Services (ATLAS) database, US Census Bureau, and National Center for Education Statistics. We included schools from 5 states with the highest, middle, and lowest poverty percentages (15 states total) and collected county median household income, percentage of students eligible for free or reduced-price lunch, race and ethnicity demographics, and access to athletic training services (full-time athletic trainer [AT], part-time AT only, no AT) for each school. Data were summarized in means, SDs, medians, interquartile ranges (IQRs), frequencies and proportions, 1-way analyses of variance, and Kruskal-Wallis tests.

RESULTS

Differences were present in school SES between schools with full-time, part-time-only, and no athletic training services. Schools with greater access to athletic training services had fewer students eligible for free or reduced-price lunch (full time: 41.1% ± 22.3%, part time only: 45.8% ± 24.3%, no AT: 52.9% ± 24.9; P < .001). Similarly, county median household income was higher in schools with increased access to athletic training services (full time median [IQR]: $56 026 [$49 085-$64 557], part time only: $52 719 [$45 355-$62 105], and no AT: $49 584 [$41 094-$57 688]; P < .001).

CONCLUSIONS

Disparities in SES were seen in access to athletic training services among a national sample of public secondary schools. Access to ATs positively influences student-athletes' health care across several measures. Pilot programs or government funds have been used previously to fund athletic training services and should be considered to ensure equitable access, regardless of school SES.

Dynamic cognitive inhibition in the context of frustration: Increasing racial representation of adolescent athletes using mobile community-engaged EEG methods

Introduction

Concussive events and other brain injuries are known to reduce cognitive inhibition, a key aspect of cognition that supports ones' behaviors and impacts regulation of mood or affect. Our primary objective is to investigate how induction of negative affect (such as frustration) impacts cognitive inhibition and the dynamic process by which youth athletes modulate responses. Secondary objective is to address the lack of Black representation in the scientific literature that promotes brain health and investigates pediatric sports-related brain injury. In particular, neuroscience studies predominantly include White participants despite broad racial representation in sport, in part due to technological hurdles and other obstacles that challenge research access for Black participants.

Methods

Using electroencephalography (EEG), we evaluate the dynamic brain processes associated with cognitive inhibition in the context of frustration induction in adolescent athletes during pre-season conditioning (i.e., prior to contact; N = 23) and a subset during post-season (n = 17).

Results

The N2 component was sensitive to frustration induction (decreased N2 amplitude, slower N2 latency), although effects were less robust at postseason. Trial-by-trial changes indicated a steady decrease of the N2 amplitude during the frustration block during the preseason visit, suggesting that affective interference had a dynamic effect on cognitive inhibition. Lastly, exploratory analyses provide preliminary evidence that frustration induction was less effective for athletes with a previous history of concussion or migraines (trending result) yet more effective for athletes endorsing a history with mental health disorders.

Discussion

We emphasize the urgent need to improve representation in cognitive neuroscience, particularly as it pertains to brain health. Importantly, we provide detailed guides to our methodological framework and practical suggestions to improve representative participation in studies utilizing high-density mobile EEG.

Influence of High School Socioeconomic Status on Athlete Injuries during the COVID-19 Pandemic: An Ecological Study

Background

It is presently unclear how the cessation of high school sport has affected injury incidence at different socioeconomic levels. The COVID-19 pandemic may have disproportionately affected athletes of lower socioeconomic status, potentially increasing injury risk in this population.

Purpose

To 1) Describe athlete injury incidence prior to and during the 2019-2020 and 2020-2021 school years in high school athletes by socioeconomic status; 2) Investigate the association between socioeconomic status and injury incidence in high school athletes.

Study Design

Ecological Study.

Methods

High schools were matched between the 2019-2020 and 2020-2021 school years. All athletes from all sports were included. High school socioeconomic status was determined by the school district median household income. Socioeconomic strata were defined as <$30,000, $30,000-50,000, $50,001-100,000, and >$100,000. Injury incidence proportion with 95% confidence interval (95% CI) was calculated for each academic year. Mixed effects negative binomial models with robust errors were performed to assess the association between the incidence proportion ratio and high school median household income. Six states and 176 high schools were included (2019-2020: 98,487 athletes; 2020-2021: 72,521 athletes).

Results

Injury incidence increased in three of four socioeconomic strata during the 2020-2021 year (<$30,000: 2019-2020: 15.6 (13.1-18.1), 2020-2021: 26.3 (23.1-29.6); $30,000-50,000: 2019-2020: 7.8 (7.1-8.6), 2020-2021: 14.9 (13.8-15.9); $50,001-100,000: 2019-2020: 15.1 (14.7-15.4), 2020-2021: 21.3 (20.9-21.8); >$100,000: 2019-2020: 18.4 (18.1-18.8), 2020-2021: 17.3 (16.8-17.7)). An association was observed between injury incidence ratio and log median high school household income in 2019-2020 [1.6 (1.1-2.5)] but not 2020-2021 [1.1 (0.8-1.6)] school years.

Conclusions

Athletes from lower socioeconomic high schools reported increased injury incidence compared to higher socioeconomic high schools during the 2020-2021 academic school year. These results highlight the increased COVID-19 pandemic vulnerability in athletes from lower socioeconomic high schools. High school sport stakeholders should consider how abrupt sport stoppage can affect lower socioeconomic athletes.

Level of Evidence

2.

Effects of Athletic Trainer Direct Employment on the Management of Sports-Related Injuries in High School Athletes

BACKGROUND

Hiring athletic trainers (ATs) in high schools has attracted rising interest as a potential way of improving adolescents' health by enhancing their safety and reducing their risk of injury.

OBJECTIVE

This study aims to determine if there is a difference in the referral patterns, injury diagnoses, and injury treatments performed at a metropolitan high school when an AT is employed versus not employed by the school.

DESIGN

This is a retrospective quantitative two-period study.

SETTING

The study was conducted in the high school athletic department in Norfolk, Virginia, and the study population was high school athletes (age 14-18).

MAIN OUTCOME MEASURES

Changes in referral patterns, injury diagnoses, and injury treatments performed at a local high school when an AT is employed versus not employed by the school; specifically, we examined the number of and percent changes in yearly treatments, referrals, evaluations, and re-evaluations during the two periods.

RESULTS

Our first t-test revealed a statistically significant increase in the number of reported injuries between 2011-2015 (M = 58.00, SD = 44.86) and 2016-2020 (M = 299.00, SD = 40.93, p = 0.006. The second t-test revealed a statistically significant increase in the number of referrals between 2011-2015 (M = 249.00, SD = 353.41) and 2016-2020 (M = 1188.00, SD = 158.21), p = 0.014. The third t-test revealed a statistically significant increase in the number of treatment items between 2011-2015 (M = 150.67, SD = 175.32) and 2016-2020 (M = 636.67, SD = 211.72), p = 0.01.

CONCLUSIONS

The present study found an increased frequency of reported injuries, referrals, and treatment after ATs directly joined the staff of a large metropolitan high school. These findings suggest that direct employment of ATs is associated with greater recording of injuries and treatment of conditions. A reduction in referrals occurs with the presence of directly employed ATs, which could result in improved health for student-athletes, but this needs further study.

Optimizing Concussion Care Seeking: Identification of Factors Predicting Previous Concussion Diagnosis Status

PURPOSE

There is limited understanding of factors affecting concussion diagnosis status using large sample sizes. The study objective was to identify factors that can accurately classify previous concussion diagnosis status among collegiate student-athletes and service academy cadets with concussion history.

METHODS

This retrospective study used support vector machine, Gaussian Naïve Bayes, and decision tree machine learning techniques to identify individual (e.g., sex) and institutional (e.g., academic caliber) factors that accurately classify previous concussion diagnosis status (all diagnosed vs 1+ undiagnosed) among Concussion Assessment, Research, and Education Consortium participants with concussion histories ( n = 7714).

RESULTS

Across all classifiers, the factors examined enable >50% classification between previous diagnosed and undiagnosed concussion histories. However, across 20-fold cross validation, ROC-AUC accuracy averaged between 56% and 65% using all factors. Similar performance is achieved considering individual risk factors alone. By contrast, classifications with institutional risk factors typically did not distinguish between those with all concussions diagnosed versus 1+ undiagnosed; average performances using only institutional risk factors were almost always <58%, including confidence intervals for many groups <50%. Participants with more extensive concussion histories were more commonly classified as having one or more of those previous concussions undiagnosed.

CONCLUSIONS

Although the current study provides preliminary evidence about factors to help classify concussion diagnosis status, more work is needed given the tested models' accuracy. Future work should include a broader set of theoretically indicated factors, at levels ranging from individual behavioral determinants to features of the setting in which the individual was injured.

Concussion Nondisclosure in Youth Sports

CONTEXT

Researchers conducting studies about sport-related concussion (SRC) reporting behaviors and reasons for nondisclosure primarily focus on older athletic populations. Youth athletes participating in contact sports are also at risk for SRC; however, little is known about their SRC disclosure patterns and reasons for nondisclosure.

OBJECTIVE

To examine the self-reported SRC history and reasons for SRC nondisclosure of youth athletes aged 8-14 years.

DESIGN

Cross-sectional study.

SETTING

Youth athletes in organized football, ice hockey, lacrosse, or soccer.

PATIENTS OR OTHER PARTICIPANTS

A total of 411 youth athletes (boys = 70.0% [n = 287/410]; median age = 11 [interquartile range = 10-13] years).

MAIN OUTCOME MEASURE(S)

A 15-minute survey including self-reported demographics, diagnosed and nondisclosed SRC history, and reasons for nondisclosure of suspected SRCs.

RESULTS

Ten percent of respondents (n = 41/411) recounted ≥1 diagnosed SRC, 12.7% (n = 52/411) did not report a suspected SRC, 13.1% (n = 53/404) indicated they continued to practice, and 12.3% (n = 50/406) reported they continued to play in a game after a suspected SRC. Significant associations between sport and nondisclosure existed (P values < .001) but not with self-reported concussion history (P = .14). In sex-comparable analyses, boys' lacrosse players had a higher frequency of nondisclosure than girls (P = .05). The most common reasons for nondisclosure were not wanting to lose playing time (66.7%, n = 32/48), miss a game (56.3%, n = 27/48), and let the team down (43.8%, n = 21/48) and uncertainty over injury severity and the presence of SRC (43.8%, n = 21/48).

CONCLUSIONS

Ten percent of youth athletes self-reported at least 1 diagnosed SRC. However, they also described continuing to practice or play in a game after a suspected SRC. Reasons for nondisclosure at this age were similar to those reported in high school and collegiate athletes. Recent researchers suggested negative consequences of continued play with SRC, especially in the acute stages. Anyone conducting future educational initiatives should emphasize these risks and focus on reasons why athletes of both sexes withhold reporting.

Physician recommended school accommodations and student outcomes following a mild traumatic brain injury among youth with persistent post-concussive symptoms

BACKGROUND

Post-concussion return-to-learn (RTL) guidelines include implementation of school accommodations. Yet, little is known about physician recommendations for school accommodations and their impact, particularly among youth experiencing persistent post-concussive symptoms (PPCS).

OBJECTIVE

We examined the association between physician recommended school accommodations and student outcomes among youth experiencing PPCS.

METHODS

Data from a randomized comparative effectiveness trial was used. Physician recommended school accommodations (≤90 days post-injury) were collected via chart abstraction. Grade point average was extracted from school records. Reports of problems at school, concussion symptoms, health-related quality of life (HRQOL), anxiety symptoms, and depressive symptoms were collected by survey (at baseline, three months, and 12 months post study entry).

RESULTS

Of 200 participants (Mage = 14.7, 62% female), 86% were recommended school accommodations. Number of recommended school accommodations was positively associated with number of school problems at three months (aRR 1.18, 95% CI:1.12-1.24) and 12 months (aRR 1.11, 95% CI:1.05-1.18). No significant associations were found between recommended school accommodations and GPA, HRQOL, anxiety symptoms, or depressive symptoms.

CONCLUSIONS

Physicians recommend more school accommodations for students experiencing more school problems post-concussion. Appropriate implementation of RTL recommendations made by physicians by fostering partnerships among physicians, students, and schools may be needed to achieve student-centered RTL.

Evidence for Economic Evaluations of Athletic Trainer Services

OBJECTIVE

Literature suggests athletic trainers (ATs) can help address health needs in a more affordable way across a variety of settings. We aimed to assess if AT services are cost-effective when compared to no AT services or services by other health providers.

DATA SOURCES

We performed a keyword search in 5 databases: Medline (FirstSearch), PubMed, Web of Science, SPORTDiscus, and Google scholar. We also conducted a generic web search to identify any informal sources that may meet the eligibility criteria.

STUDY SELECTION

We used a comprehensive list of terms to search economic evaluation studies on ATs. We included studies that met all the following criteria: economic evaluation studies on AT services; original studies written in English; and published in the last 10 years(2011-present). we excluded studies that examined either only cost or only benefit of AT services.

DATA EXTRACTION

We extracted data using a predefined checklist that included major components of economic evaluation. We also extracted data regarding athletic training practice setting.

RESULTS

We extracted 5 articles in our review, most of which supported the use of AT services as economically viable. The practice settings studied in the articles included two high school settings, two military settings, and a community outreach program that included several practice settings. Only one of the studies used standard economic evaluation methodology and took insurance status into account.

CONCLUSION

Our review shows that AT services can be a cost-effective option for addressing health care needs. However, the literature remains sparse and there was an overall lack of consistency in outcome measures, analytical methods, and reporting practices, which reduced the comparability across studies. Future studies on this topic should address these limitations, which will provide critical economic evidence to inform decision making on investing in AT services across various settings.

Medical Supervision of Illinois Public and Private High School Athletics

BACKGROUND

High-school sports participation in the United States has increased over the years with a corresponding increase in the number of injuries. Leading medical and sports organizations nationwide advocate for an increase in proper medical supervision of athletes.

OBJECTIVES

To analyze athletic medical coverage in Illinois high schools and compare differences between public and private Illinois high school.

METHODS

A survey addressing various components of sports medical coverage was distributed in 2018 to all 810 Illinois High School Association (IHSA) high schools to be completed electronically.

RESULTS

The response rate was 50% (407/810 schools). Of the responding schools, 14% were private high schools and 86% public high schools. An orthopedic surgeon, family doctor, pediatrician, or another type of physician were present on sidelines in 9.2% of private high schools and 8.5% of public high schools. Athletic trainers (ATs) were present on sidelines in 91% of private high schools and in 79% of public high schools. There was 68% of private high schools reporting coaches trained in CPR versus 85% in public high schools. Both private and public high schools had high rates of having written emergency action plans (89% vs 91%), AED on site (100% vs 99%), written concussion management protocols (96% vs 97%).

CONCLUSION

Our study found similar rates of high school medical coverage as compared to national studies, with some significant differences found between private and public high schools. Most Illinois high schools had high rates of having written EAPs, concussion management protocols and AEDs on site. Overall, an increase of medical supervision and emergency preparedness is needed, which should come in the form of increasing AT and physician presence alongside community and school engagement for improved implementation of coverage.

Factors Associated With Repeat Emergency Department Visits in a State-wide Cohort of Pediatric Patients With Mild Traumatic Brain Injury

OBJECTIVE

To describe demographic, injury, and clinical characteristics of pediatric patients treated in the ED for mild traumatic brain injury (mTBI), and to evaluate characteristics associated with mTBI-related return emergency department (ED) visit within 1 month of initial presentation.

METHODS

Retrospective cohort study from April 1, 2012, to September 30, 2017, of children 19 years or younger presenting to any Maryland ED for mTBI identified in the Maryland Health Services Cost Review Commission database using ICD-9/10 codes. Demographic, injury, and clinical characteristics of individuals were collected. The primary outcome was mTBI-related return ED visit within 4 weeks. Multiple logistic regression tested the associated of individual demographic, injury, and clinical characteristics with mTBI-related return ED visit.

RESULTS

There were 25,582 individuals who had an ED visit for mTBI, of which 717 (2.8%) returned to the ED within 4 weeks and 468 (1.8%) within 1 week with a mTBI-related diagnosis. In multivariable logistic regression analyses, public insurance (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.21-1.72) and female sex (aOR, 1.34; 95% CI, 1.15-1.56) were associated with increased odds of return to the ED within 4 weeks. Age younger than 2 years (aOR, 0.39; 95% CI, 0.21-0.72) was associated with decreased odds of return visit. There was a trend toward decreased odds of return patients receiving computed tomography head imaging (aOR, 0.86; 95% CI, 0.74-1.01).

CONCLUSIONS

Although return to the ED for mTBI-related complaints is uncommon, girls, older children, and publicly insured individuals may be at increased risk. Future targeted study may identify areas to improve access to appropriate longitudinal care and justify ED programs to better coordinate follow-up for mTBI.

The Association Between School District-Based Policies Related to Concussions and Concussions Among High School Students

BACKGROUND

Little is known about the effectiveness of school district concussion policies on reducing the concussion prevalence among students.

METHODS

Data from the 2016 School Health Policies and Practices Study and 2017 Youth Risk Behavior Survey for 10 school districts were linked. The outcome variable was having a sports- or physical activity-related concussion during the 12 months before of the survey. Exposure variables were 2 district policies, including district-funded professional development and prioritizing return to the classroom before returning to athletics. Logistic regression models estimated the odds of a concussion among students in districts with one, both, or neither policy (referent).

RESULTS

In districts with district-funded professional development, the odds of students self-reporting ≥2 sports- or physical activity-related concussions were 1.4 times higher than in districts with neither policy. In districts with a policy prioritizing a return to the classroom before returning to athletics, the odds of students self-reporting ≥2 concussions were significantly lower (OR = 0.6) than in districts with neither policy.

CONCLUSION

School district concussion policies may have positive effects by identifying and reducing multiple concussions among students.

Development of a scale to measure expected concussion reporting behavior

Background

Most concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes.

Methods

A mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9–16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155).

Results

Internal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to “always” tell their coach about symptoms of a suspected concussion.

Conclusions

The CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00364-4.

Disparities in Youth Sports and Barriers to Participation

Purpose of Review

Youth sports participation has shifted from a school-based, seasonal activity to club-based, year-round activity over the past 10–15 years. Single sport specialization has become increasingly common with a concurrent increase in injury and burnout. Paralleling trends seen in other aspects of health care, disparities in regard to participation in youth sports, and subsequent injury treatment exist as well. Recognition of these disparities amongst coaches, parents, and athletes involved in youth sports are essential to promote the short- and long-term health of pediatric and adolescent athletes.

Recent Findings

Multiple barriers exist for youth in regard to sports participation. Youth who come from families without extensive financial means are increasingly finding it difficult to play organized sports, with this trend holding when broken down by insurance status (public versus private). This problem is further exacerbated by the lack of community-based programming in locations where organized (albeit expensive) options do not exist. The lack of athletic trainers increases the divide, as well as the care that injured athletes receive (particularly in public schools within communities of color) is not equivalent to schools with extensive financial resources. Thus, ability to quickly return to play after injury and/or access the health care system is limited. This is further exemplified by inferior outcomes in regard to care for anterior cruciate ligament, meniscus, shoulder instability, and concussions in this population.

Summary

Youth sports participation is laden with multiple disparities. This is unfortunately reflective of historical barriers to opportunities/advancements in multiple other areas of society. These disparities place certain groups of children at an uphill battle not only for participation when healthy, but also returning to participation when injured. Larger structural changes in youth sports are necessary to promote life-long, healthy physical activities for individuals most at risk.

Secondary School Socioeconomic Status and Athletic Training Practice Characteristics

CONTEXT

Socioeconomic status (SES) is a significant predictor of morbidity and mortality across health outcomes. Limited information exists on how school SES impacts athletic training practice when a certified athletic trainer (AT) is present at secondary schools.

OBJECTIVE

To describe contact frequencies and service rates provided by ATs for injuries among secondary school student athletes and how these differ by school SES.

DESIGN

Cross-sectional study Setting: Athletic training room (ATR) visit days and AT services were collected from 77 secondary schools. Schools were separated into three school SES groups: affluent (n=31), average (n=29), and disadvantaged (n=17).

PATIENTS OR OTHER PARTICIPANTS

Secondary school student-athletes participating in 12 boys' and 11 girls' sports who visited the ATR during the 2014-2015 through 2018-2019 academic years and received athletic or non-athletic injury care.

MAIN OUTCOME MEASURES

Contact frequencies expressed as ATR visit days per injury, AT services per injury, and AT services per ATR visit day. Rates for service type utilized were expressed as the total count over reported athlete-exposures.

RESULTS

ATs documented 1,191 services. Affluent and average SES school communities provided greater contact frequencies for injury related care compared to disadvantaged school communities, particularly by AT services/injury (7.10±13.08 versus average: 9.30±11.60 and affluent: 9.40±12.20; p=0.020). Affluent school communities provided greater rates of services in five of the eleven service groups reported. No significant differences were observed among school SES groups in therapeutic exercises.

CONCLUSIONS

Our findings reflect that AT practice characteristics may differ by school SES, but these differences do not appear to result in less medical care. Given the complexity and widespread effects of SES, future investigations should utilize a complex method to determine SES as well as aim to identify how SES may impact secondary school student athletes outside of AT practice characteristics.

Healthcare Navigation of Black and White Adolescents Following Sport-Related Concussion: A Path Towards Achieving Health Equity

CONTEXT

Care-seeking behaviors for sport-related concussion (SRC) are not consistent across demographic subgroups. These differences may not only stem from health inequities but can further perpetuate disparities in care for SRCs.

OBJECTIVE

To determine whether racial differences exist in the care pathway from injury to SRC clinic within adolescent athletes.

DESIGN

Retrospective cohort Setting: Regional SRC center Participants: Of 582 total athletes, 486 (83.5%) White and 96 (16.5%) Black adolescent athletes were diagnosed with SRC and evaluated within 3 months at the SRC clinic.

MAIN OUTCOME MEASURES

Race was the defined exposure, dichotomized as Black or White. The four primary outcomes included: 1)location of first health system contact, 2)time from injury to first health system contact 3) time to in-person SRC clinic visit, and 4) whether the athlete established care (>1 visit), was released immediately to an athletic trainer, or lost to follow-up.

RESULTS

Black and White athletes mostly presented directly to SRC clinic (61.5% vs 62.3%) at a median[interquartile range] of 3[1,5] vs 4[1,8] days respectively (p=0.821). Similar proportions of Black and White athletes also first presented to the ED (30.2% vs 27.2%) at a median of 0[0,1] vs 0[0,1] days (p=0.941). Black athletes more frequently had care transferred to their athletic trainer (39.6% vs 29.6%) and less frequently established care (56.3% vs 64.0%), however these differences were not statistically significant (p=0.138). Lost to follow-up was uncommon among Black and White athletes alike (4.2% vs 6.4%).

CONCLUSIONS

This study demonstrated that within an established SRC referral network and multidisciplinary clinic, there were no observed racial disparities in how athletes were initially managed and/or ultimately presented to SRC clinic despite racial differences in school type and insurance coverage. SRC center assimilation and affiliation with school systems may be helpful in improving access and providing equitable care across diverse patient demographics.

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.

The Underreporting of Concussion: Differences Between Black and White High School Athletes Likely Stemming from Inequities

Previous studies have found that Black high school athletes have poorer knowledge about concussions and have fewer sports medicine healthcare resources than White athletes, but research on concussion disclosure by race is still needed. Therefore, the purpose of this study was to examine racial differences in concussion reporting behaviors between Black and White high school athletes. This cross-sectional study administered surveys to 577 high school athletes (64.5% Black; 72.3% males; 16.02 ± 1.2 years) from 14 schools (title I, n = 9; non-title I, n = 5). The survey included self-reported items on concussions and bell-ringers experienced during games and practices and the number of these episodes that were reported to an authoritative figure. Reasons for reporting and not reporting were also assessed. Results found that White athletes were more likely to recall experiencing a bell-ringer in games compared with Black athletes. They were also more likely to report a bell-ringer or concussion that occurred in a game. There was a significantly higher proportion of Black athletes compared with White athletes that did not report their bell-ringer experienced in games and concussions experienced in practices. White athletes were more likely than Black athletes to disclose a concussion because they thought they had a concussion, while there were no racial differences in the reasons for not reporting. The findings of this study highlight the critical role that race, as a social determinant of health, may play in concussion reporting in high school athletes. Future public health efforts should seek to further understand and overcome inequities in healthcare resources for concussion education and management.

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.

Pupillary changes after clinically asymptomatic high-acceleration head impacts in high school football athletes

OBJECTIVE

Previous studies have shown that clinically asymptomatic high-acceleration head impacts (HHIs) may be associated with neuronal and axonal injury, as measured by advanced imaging and biomarkers. Unfortunately, these methods of measurement are time-consuming, invasive, and costly. A quick noninvasive measurement tool is needed to aid studies of head injury and its biological impact. Quantitative pupillometry is a potential objective, rapid, noninvasive measurement tool that may be used to assess the neurological effects of HHIs. In this study, the authors investigated the effect of HHIs on pupillary metrics, as measured using a pupillometer, in the absence of a diagnosed concussion.

METHODS

A prospective observational cohort study involving 18 high school football athletes was performed. These athletes were monitored for both the frequency and magnitude of head impacts that they sustained throughout a playing season by using the Head Impact Telemetry System. An HHI was defined as an impact exceeding 95g linear acceleration and 3760 rad/sec2 rotational acceleration. Pupillary assessments were performed at baseline, midseason, after occurrence of an HHI, and at the end of the season by using the NeurOptics NPi-200 pupillometer. The Sport Concussion Assessment Tool, 5th Edition (SCAT5), was also used at each time point. Comparisons of data obtained at the various time points were calculated using a repeated-measures analysis of variance and a t-test.

RESULTS

Seven athletes sustained HHIs without a related diagnosed concussion. Following these HHIs, the athletes demonstrated decreases in pupil dilation velocity (mean difference 0.139 mm/sec; p = 0.048), percent change in pupil diameter (mean difference 3.643%; p = 0.002), and maximum constriction velocity (mean difference 0.744 mm/sec; p = 0.010), compared to measurements obtained at the athletes' own midseason evaluations. No significant changes occurred between the SCAT5 subtest scores calculated at midseason and those after a high impact, although the effect sizes (Cohen's d) on individual components ranged from 0.41 to 0.65.

CONCLUSIONS

Measurable changes in pupil response were demonstrated following an HHI. These results suggest that clinically asymptomatic HHIs may affect brain reflex pathways, reflecting a biological injury previously seen when more invasive methods were applied.

Athletic trainer employment, physician access and care delivery in secondary schools

Objective: To evaluate the source of employment of athletic trainers (ATs), access to team physicians, and usage of up-to-date (implementation of the most current international sports medicine societies' position statements and evidence-based literature policy and procedure manuals in secondary schools. Methods: We conducted a cross-sectional study among National Athletic Trainers' Association (NATA) members. NATA 'Research Survey Request' was contacted to obtain 1,000 e-mail addresses of ATs who actively worked in the secondary school setting. We evaluated AT employment, access to team physicians, and usage of up-to-date policy and procedure manuals within different residential areas (urban, suburban, and rural) and school distinctions (public vs. private). Results: Two-hundred ninety-six responses were received (30% response rate). The majority (72%) of ATs reported having an assigned team physician for their school. Approximately one-third (36%) of ATs reported being employed by a hospital, clinic, or outreach facility. Fifty-one percent of ATs reported having a policy and procedure manual that was developed and reviewed with their team physician. There was a significantly greater amount of suburban ATs who reported having an up-to-date policy and procedure manual (urban 45% vs. suburban 60% vs. rural 39%; p = 0.007). Significantly more ATs who were employed in a public school setting reported conducting annual policy and procedure manual reviews than those employed in private school settings (public 63% vs. private 49%; p = 0.045). Conclusions: The majority of ATs have assigned team physicians and a third is employed by a medical group. A high number of ATs reported not having a policy and procedure manual that was developed and reviewed with their team physician. Sports medicine teams within secondary schools, particularly in private schools, should strive to develop and maintain an up-to-date policy and procedure manual that is frequently reviewed with their team physician.

The cost of a single concussion in American high school football: a retrospective cohort study

AIM

The potential financial burden of American football-related concussions (FRC) is unknown. Our objective was to describe the healthcare costs associated with an FRC and determine factors associated with increased costs.

METHODOLOGY/RESULTS

A retrospective cohort study of concussed high school football players presenting between November 2017 and March 2020 was undertaken; 144 male high school football players were included. Total costs were about $115,000, for an average direct healthcare cost of $800.10/concussion. Visiting the emergency department (β = 502.29, 95% CI: 105.79-898.61; p = 0.01), the initial post-concussion symptom scale score (β = 0.39, 95% CI: 0.11-0.66; p = 0.01) and a post-concussion syndrome diagnosis (β = 670.37, 95% CI: 98.96-1241.79; p = 0.02) were each independently associated with total costs.

CONCLUSION

A granular understanding of cost-driving factors associated with FRC is the first step in understanding the cost-effectiveness of prevention and treatment methods.

Examination of Racial Disparities in Adolescents Seen in the Emergency Department for Head, Neck, or Brain Injury

BACKGROUND

Given the frequency, severity, and attention of traumatic brain injury in children, benchmarking disparities and injury characteristics for adolescent patients is pivotal in understanding and enhancing both clinical care and outcomes.

OBJECTIVES

The purpose of this study was to investigate racial disparities on mechanism of injury, clinical outcomes, and social-health factors among adolescents treated in the emergency department (ED) for a head, neck, or brain injury.

METHODS

This study is the result of a retrospective chart review of head-, neck-, and brain-injured adolescent patients (n = 2857) treated at three community hospital EDs and one stand-alone ED. Outcome measures included patient demographics (gender, race/ethnicity, age), Glasgow Coma Scale score, hospital length of stay, intensive care unit length of stay, mechanism of injury, primary diagnosis, secondary diagnosis of a concussion, ventilation days, discharge disposition, and primary insurance.

RESULTS

There were racial differences in primary diagnosis, mechanism of injury, and insurance status. Results indicated that a higher proportion of white patients were diagnosed with a concussion compared with black patients (p < 0.001). Moreover, a higher proportion of white patients were seen in the ED for head, neck, or brain injury as a result of a sports or motor vehicle incident, whereas a leading mechanism among black patients was assault (p = 0.01). More white patients had private insurance, whereas more black patients had Medicaid (p < 0.001).

CONCLUSION

The disparities in mechanisms for which black and white adolescent patients are seeking care at the ED for head, neck, or brain injury help to identify social-health risks of sustaining a head, neck, or brain injury. These racial disparities between black and white adolescents seen at the ED for head, neck, or brain injury suggest the need for further research to better understand the national representation of these disparities.

Assessment of HEADS UP online training as an educational intervention for sports officials/athletic trainers

BACKGROUND

Sports- and recreation-related concussions are a common injury among children. Sports officials (SOs) and athletic trainers (ATs) are integral to setting the stage for safe play and managing concussions when they occur, and significant numbers of both groups have completed the Centers for Disease Control and Prevention's HEADS UP online concussion training course. However, the utility of the course for these audiences has not been assessed. We hypothesized that sports officials' and athletic trainers' concussion-related knowledge, attitudes, and behavioral intentions will improve from pre- and post-test after completing CDC's HEADS UP online concussion training course.

METHOD

Respondents' concussion-related knowledge, attitudes, and behavioral intentions were assessed both before and after taking the training course. Differences between pre- and post-test scores were calculated based on the Wilcoxon Signed Rank Test Z-score or McNemar's test. Effect sizes were interpreted.

RESULTS

The SOs and ATs who participated in the HEADS UP online training had a high level of concussion knowledge before taking the course: 90% or more of respondents could identify the correct response for at least seven of the 13 knowledge questions in the pre-test. Still, the course was effective at improving the respondents' knowledge about return-to-play protocols and concussion reporting. Further, SOs and ATs demonstrated improvement in their concussion-related attitudes and behavioral intentions between the pre- and post-test.

CONCLUSION

SOs' and ATs' concussion knowledge, attitudes, and behavioral intentions improved immediately following completion of the CDC HEADS UP online training. Future research could also focus on the long-term retention of this type of training. Practical Applications: This study provides insight into how to better focus concussion-related educational programs to fit SOs' and ATs' needs.

Developing a Comprehensive, Interdisciplinary Concussion Program

There has been a growing trend of local and national coverage of and interest in concussion injuries over the past 2 decades. Increasing public concern over potential catastrophic and unknown long-term effects of sports-related concussion injuries has led to an acknowledgment of the strong public health need for addressing all concussion injuries, regardless of mechanism of injury. In efforts to address this need for concussion prevention and management, both in sports and nonsports, The University of Kansas Health System initiated the interdisciplinary Center for Concussion Management program in 2012. The program was created as a virtual clinic concept and includes voluntary participation from various providers across the institution, limited budget, and space obstacles. Since its inception, the program has continued to operate as its initial design of a multidisciplinary team model outside the sole ownership of 1 department, and has expanded to include education and outreach to local and regional schools and groups.

Concussion Experiences in New England Private Preparatory High School Students Who Played Sports or Recreational Activities

BACKGROUND

Sports- and recreation-related (SRR) activities are a major cause of adolescent concussions. Most adolescent SRR concussion research has been conducted among public school students. As private schools are qualitatively different from public schools (eg, location, socioeconomic status, sports played), this study explores the concussion experiences of a large group of private high school students.

METHODS

We surveyed 2047 New England private preparatory high school students who played sports or engaged in a recreational activity in 2018 about the sports they played, and their self-reported concussion experiences (eg, age at first concussion, if concussions were sports- or recreation-related). Descriptive, bivariate, and multivariate statistics are presented.

RESULTS

One-third (33.0%) of students who reported engaging in sport- or recreation-related activities self-reported experiencing a concussion in their lifetime. A higher percentage of boys, students who played contact sports, and those who played multiple seasons of school sports reported a concussion. Sex, contact level of primary sport played, and age of first concussion were also significantly associated with reporting a sports- or recreation-related concussion.

CONCLUSIONS

A sizeable proportion of private preparatory high school students reported experiencing a concussion, with some students at higher risk. Private preparatory high school-specific concussion prevention strategies may be needed.

Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations

Background  Mild-traumatic brain injury (mTBI) and concussions cause significant morbidity. To date, synthesis of specific health care disparities and gaps in care for rural mTBI/concussion patients remains needed. Methods  A comprehensive literature search was performed using PubMed database for English articles with keywords "rural" and ("concussion" or "mild traumatic brain injury") from 1991 to 2019. Eighteen articles focusing on rural epidemiology ( n = 5), management/cost ( n = 5), military ( n = 2), and concussion prevention/return to play ( n = 6) were included. Results  mTBI/concussion incidence was higher in rural compared with urban areas. Compared with urban patients, rural patients were at increased risk for vehicular injuries, lifetime number of concussions, admissions for observation without neuroimaging, and injury-related costs. Rural patients were less likely to utilize ambulatory and mental health services following mTBI/concussion. Rural secondary schools had decreased access to certified personnel for concussion evaluation, and decreased use of standardized assessment instruments/neurocognitive testing. While school coaches were aware of return-to-play laws, mTBI/concussion education rates for athletes and parents were suboptimal in both settings. Rural veterans were at increased risk for postconcussive symptoms and posttraumatic stress. Telemedicine in rural/low-resource areas is an emerging tool for rapid evaluation, triage, and follow-up. Conclusions  Rural patients are at unique risk for mTBI/concussions and health care costs. Barriers to care include lower socioeconomic status, longer distances to regional medical center, and decreased availability of neuroimaging and consultants. Due to socioeconomic and distance barriers, rural schools are less able to recruit personnel certified for concussion evaluation. Telemedicine is an emerging tool for remote triage and evaluation.

Examination of sports and recreation-related concussion among youth ages 12-17: results from the 2018 YouthStyles survey

Background: This paper sought to examine the frequency of self-reported sports- and recreation-related (SRR) concussion, as well as care-seeking behaviors and potential activity restrictions after concussions, in a sample of youth.Methods: A sample of 845 youth ages 12-17 years responded to the web-based YouthStyles survey in 2018. The survey measured the frequency of self-reported lifetime SRR concussion, the setting of their most recent SRR concussion, whether a doctor or nurse evaluated them, and the types of activity restrictions they experienced.Results: Forty-three percent of youth surveyed sustained their most recent concussion while playing on a sports team, 21.1% while playing on a community-based team, and 36.0% while engaged in a sport or recreational activity. Nearly half (45.3%) reported having to miss playing sports or participating in physical activity for at least one day; about two in ten (19.7%) reported having to miss time on their phone or computer for at least one day.Conclusion: Despite wide-spread efforts to promote protocols for SRR concussion among youth, a third of participants in this study did not seek medical care and more than half did not miss at least one day of sports or physical activity participation following a concussion.

A Comparison of Emergency Preparedness Between High School Coaches and Club Sport Coaches

CONTEXT

Recent studies suggested that a large population of high school-aged athletes participate on club sport teams. Despite attempts to document emergency preparedness in high school athletics, the adherence to emergency and medical coverage standards among club sport teams is unknown.

OBJECTIVE

To determine if differences in emergency preparedness and training existed between coaches of high school teams and coaches of high school-aged club teams.

DESIGN

Cross-sectional survey.

SETTING

Online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

A total of 769 coaches (females = 266, 34.6%) completed an anonymous online questionnaire regarding their emergency preparedness and training.

MAIN OUTCOME MEASURE(S)

The questionnaire consisted of (1) demographics and team information, (2) emergency preparedness factors (automated external defibrillator [AED] availability, emergency action plan [EAP] awareness, medical coverage), and (3) emergency training requirements (cardiopulmonary resuscitation/AED, first aid).

RESULTS

High school coaches were more likely than club sport coaches to be aware of the EAP for their practice venue (83.9% versus 54.4%, P < .001), but most coaches in both categories had not practiced their EAP in the past 12 months (70.0% versus 68.9%, P = .54). High school coaches were more likely to be made aware of the EAP during competitions (47.5% versus 37.1%, P = .02), but the majority of coaches in both categories indicated that they were never made aware of EAPs. High school coaches were more likely than club coaches to (1) have an AED available at practice (87.9% versus 58.8%, P < .001), (2) report that athletic trainers were responsible for medical care at practices (31.2% versus 8.8%, P < .001) and competitions (57.9% versus 31.2%, P < .001), and (3) be required to have cardiopulmonary resuscitation, AED, or first-aid training (P < .001).

CONCLUSIONS

High school coaches displayed much greater levels of emergency preparedness and training than coaches of high school-aged club teams. Significant attention and effort may be needed to address the lack of emergency preparedness and training observed in club coaches.

Access to Athletic Trainer Services in California Secondary Schools

CONTEXT

California is currently the only state that does not regulate who can and cannot call themselves athletic trainers (ATs). Therefore, previous national or state-specific investigations may not have provided an accurate representation of AT availability at the secondary school level in California. Similarly, it is unknown whether the factors that influence AT availability in California, such as socioeconomic status, are similar to or different from those identified in previous studies.

OBJECTIVE

To describe the availability of ATs certified by the Board of Certification in California secondary schools and to examine potential factors influencing access to AT services in California secondary schools.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Representatives of 1270 California high schools.

MAIN OUTCOME MEASURE(S)

Officials from member schools completed the 2017-2018 California Interscholastic Federation Participation Census. Respondents provided information regarding school type, student and student-athlete enrollment, whether the school had ATs on staff, and whether the ATs were certified by the Board of Certification. The socioeconomic status of public and charter schools was determined using the percentage of students eligible for free or reduced-price lunch.

RESULTS

More than half (54.6%) of schools reported that they either did not employ ATs (47.6%) or employed unqualified health personnel (UHP) in the role of AT (7.0%). Nearly 30% of student-athletes in California participated in athletics at a school that did not employ ATs (n = 191 626, 28.9%) and 8% of student-athletes participated at a school that employed UHP in the role of AT (n = 54 361, 8.2%). Schools that reported employing ATs had a lower proportion of students eligible for free or reduced-price lunch than schools that did not employ ATs and schools that employed UHP (both P values < .001).

CONCLUSIONS

With ongoing legislative efforts to obtain regulation of ATs in California, secondary school administrators are encouraged to hire ATs with the proper certification to enhance the patient care provided to student-athletes and improve health outcomes.

Effectiveness of the US Centers for Disease Control and Prevention HEADS UP coaches' online training as an educational intervention

BACKGROUND

Concussions are common among youth athletes. Responsibility for the recognition and management of concussion is often put on coaches. To equip coaches with appropriate knowledge and skills, the US Centers for Disease Control and Prevention (CDC) launched the HEADS UP: Concussion in Youth Sports online training.

OBJECTIVES

To determine whether HEADS UP coaches' training improves knowledge, attitudes and behavioural intentions.

METHODS

Knowledge questions were grouped into scales by level of difficulty. Differences between pre-and post-test scores were calculated based on the Wilcoxon Signed Rank Test Z-score and effect sizes were interpreted.

RESULTS

Coaches displayed a high level of knowledge in the pre-test. While lower difficulty questions did not show improvement from pre- to post-test, moderate and high difficulty questions did. Use of the training was associated with improved knowledge about symptom resolution, return-to-play recommendations and under-reporting of incidents of concussion. Coaches demonstrated improvement in five of the seven concussion-related attitude and behavioural intention items post training.

CONCLUSION

HEADS UP training improved coaches' knowledge on select topics and helped them feel more comfortable about responding to concussion among their athletes. This study provides insight into how to better focus future HEADS UP concussion health education efforts to fit coaches' informational needs.

Sports-Related Concussion in Adolescent Gaelic Games Players

BACKGROUND

Gaelic games are some of the most popular sports played by Irish adolescents, and the Gaelic Athletic Association has undertaken educational initiatives to improve awareness of a sports-related concussion (SRC). However, SRC underreporting is common among adolescent athletes internationally, potentially due to poor knowledge or attitudes toward SRC. This study aimed to examine previous experiences with, knowledge of, and attitudes toward reporting SRCs, as well as views on future education in adolescent Gaelic games players and their parents.

HYPOTHESES

The hypotheses were as follows: (1) A significant number of adolescent Gaelic games players will have experienced an SRC, (2) nondisclosure of SRCs will be common, and (3) adolescents will display poorer attitudes toward reporting than parents.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Adolescent male and female Gaelic games players (n = 113) and parents (n = 151) completed an anonymous questionnaire examining previous experiences with, knowledge of, and attitudes toward reporting SRCs, as well as views on future SRC education initiatives.

RESULTS

Overall, 57.5% of adolescent Gaelic games players suspected they had suffered an SRC previously, and a greater number of suspected SRCs were reported than were medically diagnosed. Adolescent players (mean score, 11.4/14) and their parents (mean score, 11.8) displayed good knowledge of SRC signs and symptoms. However, adolescents were less likely to report an SRC during an important game or if an important game was coming up. Both adolescents and their parents would like more SRC education, particularly in the format of online videos or medical professional-led workshops.

CONCLUSION

Underreporting of SRC occurs in adolescent players, despite good knowledge of SRC signs and symptoms. Education is required to highlight the importance of completing a return-to-play program after an SRC regardless of match importance.

CLINICAL RELEVANCE

A multifaceted educational strategy that targets the wider Gaelic games community in the preferred formats identified by key stakeholders is required.

Racial and Ethnic Differences in Emergency Department Utilization and Diagnosis for Sports-Related Head Injuries

Background: Prior studies have shown racial differences in concussion awareness and outcome.

Objective: To assess if racial or ethnic differences exist in Emergency Department (ED) utilization and diagnosis for children with sports-related head injuries.

Methods: We performed a retrospective, cross-sectional analysis of ED visits from 2008 to 2017 using National Electronic Injury Surveillance System (NEISS) data. Population-weighted ED visits for children age 7–18 years with a sport-related injury were included. We compared the probability of an ED visit being for an injury to the head or diagnosed as a concussion between children of different races/ethnicities. Analyses were adjusted for age, gender, sport, year, and location where the injury occurred.

Results: We identified 11,529,994 population-weighted ED visits for pediatric sports-related injuries, of which 1,497,717 (13.0%) were injuries to the head and 619,714 (5.4%) received a diagnosis of concussion. Black children were significantly less likely than non-Hispanic white children to have their ED visit be for an injury to the head [Odds Ratio (OR) 0.72, 95%CI 0.65–0.79] or concussion (OR 0.58, 95%CI 0.50–0.68). Black children presenting to the ED with an injury to their head were less likely than non-Hispanic white children to be diagnosed with a concussion (OR = 0.71, 95%CI 0.59–0.85).

Conclusions: Racial differences exist in both ED utilization for pediatric sports-related head injuries and in the diagnosis of concussion. Further work is needed to understand these differences to ensure all brain injured athletes receive optimal care, regardless of race.

The impact of high school athletic trainer services on medical payments and utilizations: a microsimulation analysis on medical claims

Background

Increasing athletic trainer (AT) services in high schools has attracted widespread interest across the nation as an effective instrument to manage injuries and improve children’s health, but there is a lack of evidence on potential medical savings. Our study aimed to address this knowledge gap and provide evidence of AT impacts on medical payments and utilizations to inform public policy decision.

Methods

We obtained medical claims of patients aged 14 to 18 years from the 2011–2014 Oregon All Payer All Claims limited dataset. We calculated payer payments and utilizations for medical claims under AT’s scope of practice. We used zip codes to link patients with the enrollment boundaries of Oregon public high schools, which were classified as either “AT group” or “non-AT group”. We implemented an innovative microsimulation analysis to address the uncertainty of linkage between children and schools.

Results

Our analysis included 64,115 and 84,968 eligible children with Medicaid and commercial insurance, respectively. Associated with high school AT services, Medicaid saved an average of $64 per patient during the study period, while commercial insurance payment rarely changed. AT services may reduce emergency visits for both insurance types but increase total visits for commercially insured patients.

Conclusions

Our study provides evidence for the differential impacts of AT services on medical payments and utilizations. The legislators should consider to allocate funds for high schools to directly employ ATs. This will encourage ATs to work to their highest ability to improve children’s wellbeing while containing avoidable medical cost.

Youth and high school sports coaches' experience with and attitudes about concussion and access to athletic trainers by sport type and age of athlete coached

INTRODUCTION

Concussions are a commonly reported injury in youth and high school sports and much of the responsibility related to concussion identification and response for young athletes is allocated to sports coaches. This paper presents findings on concussion-related education, access to resources, experiences, and attitudes among a large number of youth and high school sports coaches across a variety of sports nationwide.

METHODOLOGY

Data were collected among coaches who completed the Centers for Disease Control and Prevention's (CDC) HEADS UP online concussion training pre-test between November 2016 and November 2017. Coaches' concussion-related education, access to resources, experiences, and attitudes were compared by age of athlete coached and level of contact of sport. Medium and large effect sizes were considered of practical significance for interpretation.

RESULTS

During the study period, 187,801 youth sports or high school sports coaches completed the CDC HEADS UP online training and corresponding pre-test. Access to previous concussion training significantly varied among respondents by age of athlete coached. For example, 27.4% of coaches of athletes aged 5 and younger had taken previous training compared to 72.9% of coaches of athletes aged 14-18. About one-quarter (27.4%) of all coaches reported ever having had to pull an athlete out of a game because of a possible concussion and 19.5% reported access to an athletic trainer at all games and practices. These variables differed significantly among coaches by age of athletes coached; coaches of older athletes were more likely to report access to an athletic trainer and having had to pull an athlete out of a game compared to coaches of younger athletes. No statistical differences by level of contact were considered to be of practical significance based on effect size.

CONCLUSION

Most coaches in this study report having access to education and hold attitudes consistent with best practices about concussion safety; however, overall access to concussion-related resources is limited. While differences in access to concussion-related education, experience, resources, and attitudes among coaches of varying levels of contact were small, medium to large variations were identified by age of athlete coached. Practical applications: Coaches bear an important part of the responsibility to prevent, identify, and manage concussions in young athletes. Tailored educational efforts may assist coaches of young athletes with recognition of concussion signs and symptoms and with feeling comfortable deciding whether an athlete needs to be evaluated for a possible concussion.

The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys' Wrestling (2005-2006 Through 2013-2014) and National Collegiate Athletic Association Men's Wrestling (2004-2005 Through 2013-2014)

CONTEXT

The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of wrestling injury data.

OBJECTIVE

To describe the epidemiology of injuries sustained in high school boys' wrestling in the 2005-2006 through 2013-2014 academic years and collegiate men's wrestling in the 2004-2005 through 2013-2014 academic years using Web-based sports injury surveillance.

DESIGN

Descriptive epidemiology study.

SETTING

Online injury surveillance from wrestling teams of high school boys (annual average = 100) and collegiate men (annual average = 11).

PATIENTS OR OTHER PARTICIPANTS

Male wrestlers who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school or the 2004-2005 through 2013-2014 academic years in college.

MAIN OUTCOME MEASURE(S)

Athletic trainers collected time-loss (≥24 hours) injuries and exposure data during this time period. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios with 95% confidence intervals, and injury proportions by body site and diagnosis were calculated.

RESULTS

The High School Reporting Information Online documented 3376 time-loss injuries during 1 416 314 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 2387 time-loss injuries during 257 297 AEs. The total injury rate was higher in college than in high school (9.28 versus 2.38/1000 AEs; injury rate ratio = 3.89; 95% confidence interval = 3.69, 4.10). In high school, the most commonly injured body parts for both practices and competitions were the head/face (practices = 19.9%, competitions = 21.4%) and shoulder/clavicle (practices = 14.1%, competitions = 21.0%). In college, the most frequently injured body parts for both practices and competitions were the knee (practices = 16.7%, competitions = 30.4%) and head/face (practices = 12.1%, competitions = 14.6%).

CONCLUSIONS

Injury rates were higher in collegiate than in high school players, and the types of injuries sustained most often differed. Based on these results, continued study of primary and secondary prevention of injury in wrestlers across levels of competition is warranted.