Mechanisms of team-sport-related brain injuries in children 5 to 19 years old: opportunities for prevention

Impact Deceleration Differences on Natural Grass Versus Synthetic Turf High School Football Fields

American football has the highest rate of concussions in United States high school sports. Within American football, impact against the playing surface is the second-most common mechanism of injury. The objective of this study was to determine if there is a difference in impact deceleration between natural grass and synthetic turf high school football fields. A Century Body Opponent Bag (BOB) manikin was equipped with a Riddell football helmet and 3 accelerometers were placed on the forehead, apex of the head, and right ear. The manikin was dropped from a stationary position onto its front, back, and left side onto natural grass (n = 10) and synthetic turf (n = 9) outdoor football fields owned and maintained by public and private institutions on O'ahu, Hawai'i. Data was collected on 1,710 total drops. All accelerometers in forward and backward falls, and 1 accelerometer in side falls showed significantly greater impact deceleration on synthetic turf compared to the natural grass surfaces (P < .05). The results of this study provide evidence-based rationale to inform youth sports policies, particularly those aimed at injury prevention through safer playing environments and equipment.

Associations between the circumstances and severity of head impacts in men's university ice hockey

Improved evidence on the most common and severe types of head impacts in ice hockey can guide efforts to preserve brain health through improvements in protective gear, rink design, player training, and rules of play. In this observational cohort study of men's university hockey, we compared video evidence on the circumstances of 234 head impacts to measures of head impact severity (peak linear accelerations and rotational velocities) from helmet-mounted sensors (GForceTracker). Videos were analyzed with a validated questionnaire, and paired with helmet sensor data. Shoulder-to-head impacts were more common than hand- or elbow-, but there were no differences in head impact severity between upper limb contact sites (p ≥ 0.2). Head-to-glass impacts were nearly four times more common, and just as severe as head-to-board impacts (p ≥ 0.4). Head impacts resulting in major penalties (versus no penalty), or visible signs of concussion (versus no signs), involved greater head rotational velocities (p = 0.038 and 0.049, respectively). Head impacts occurred most often to the side of the head, along the boards to players in their offensive zone without puck possession. Head impact severity did not differ between cases where the head was (versus was not) the primary site of contact (p ≥ 0.6). Furthermore, penalties were called in only 4% of cases where the head was the initial point of contact. Accordingly, rules that focus on primary targeting of the head, while important and in need of improved enforcement, offer a limited solution.

The Incidence, Cost, and Burden of Concussion in Women's Rugby League and Rugby Union: A Systematic Review and Pooled Analysis

BACKGROUND

The extent of concussion injury in the rugby codes for women is unclear.

OBJECTIVE

Our aim was to review all published studies reporting concussion injuries from match and training participation in rugby codes and report the pooled data estimates for rugby league and union concussion injury epidemiology.

METHODS

We conducted a systematic literature analysis of concussion in rugby league and rugby union for published studies from January 1990 to July 2021. Data from 16 studies meeting the inclusion criteria were extracted for women's concussion injuries and were subsequently pooled. Costs from Accident Compensation Corporation (ACC) data were attributed to the results to provide cost estimates.

RESULTS

The pooled analysis match injury incidence of women's concussion was higher for rugby league (10.3 per 1000 match hours) than rugby 15 s (2.8 per 1000 match hours) or rugby 7 s (8.9 per 1000 match hours). There was a fourfold difference in the pooled incidence of concussion in women's rugby league (risk ratio [RR] 4.53, 95% confidence interval [CI] 1.8-11.3]; p = 0.0001) when compared with rugby 15 s. There was also a ninefold higher risk of a concussion during match participation compared with training participation for women's rugby 15 s (RR 9.3, 95% CI 1.29-66.78; p = 0.0070). The total estimated costs for the concussions reported were NZ$1,235,101. For rugby 7 s, the pooled concussive injury burden was 33.2 days.

CONCLUSIONS

Our pooled analysis clarified the extent of concussion injury and the possible associated costs at several levels of the game for women's rugby codes. The pooled mean days lost because of concussions was 33 days. As this was considerably longer than the 7- to 10-day expected timeframe outlined in the Concussion in Sport Consensus statement, these guidelines need to be updated to include sex-specific differences.

Imaging of Hockey-related Injuries of the Head, Neck, and Body

Hockey is a demanding contact sport with growing popularity around the world. This article is part of a review series in this issue of Seminars in Musculoskeletal Radiology that summarizes epidemiological research on the patterns of ice hockey injuries as well as provides pictorial examples for a radiologist's perspective. We focus on non-extremity pathologies which encompass many of the most devastating injuries of hockey, namely those involving the head, neck, face, spine, and body.

Video analysis of potential concussions in elite male Hurling: are players being assessed according to league guidelines?

Background

Hurling is a fast-paced contact sport that places players at risk of concussion. Given the consequences of repeated concussive impacts, it is imperative that concussion management guidelines are followed.

Hypothesis/Purpose.

The aim of this study is to determine if potential concussive events (PCEs) in elite Hurling are assessed in accordance with league management guidelines. The secondary objective is to investigate the effectiveness of current concussion training programs.

Methods

Investigators used a video analysis approach to identify PCEs throughout the 2018 and 2019 inter-county Hurling seasons and championships. Subsequent assessment, return to play (RTP) decision, and signs of concussion were evaluated based on previously validated methods. The results were then compared year-over-year with previous research in Gaelic Football (GF).

Results

A total of 183 PCEs were identified over 82 matches. PCEs were frequently assessed (86.3%, n = 158) by medical personnel. The majority of assessments were less than 1 min in duration (81.0%, n = 128). Thirteen (7.1%) players were removed following a PCE. There were 43 (23.5%) PCEs that resulted in one or more signs of concussion, of which 10 (23.3%) were removed from play. There was no difference in rate of assessment, duration of assessment, or rate of RTP between 2018 and 2019 in both Hurling and GF, suggesting that current concussion training programs have had limited success.

Conclusion

In Hurling, players suspected of having sustained a concussion are frequently subject to a brief assessment, and are rarely removed from play. Affirmative action is needed to ensure the consistent application of standardized concussion assessment across the Gaelic Games.

Surveillance from the high ground: sentinel surveillance of injuries and poisonings associated with cannabis

INTRODUCTION

In October 2018, Canada legalized the nonmedical use of cannabis for adults. The aim of our study was to present a more recent temporal pattern of cannabis-related injuries and poisonings found in the electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP) database and provide a descriptive summary of the injury characteristics of cannabis-related cases captured in a nine-year period.

METHODS

We conducted a search for cannabis-related cases in the eCHIRPP database reported between April 2011 and August 2019. The study population consisted of patients between the ages of 0 and 79 years presenting to the 19 selected emergency departments across Canada participating in the eCHIRPP program. We calculated descriptive estimates examining the intentionality, external cause, type and severity of cannabis-related cases to better understand the contextual factors of such cases. We also conducted time trend analyses using Joinpoint software establishing the directionality of cannabis-related cases over the years among both children and adults.

RESULTS

Between 1 April 2011, and 9 August, 2019, there were 2823 cannabis-related cases reported in eCHIRPP, representing 252.3 cases/100 000 eCHIRPP cases. Of the 2823 cannabis-related cases, a majority involved cannabis use in combination with one or more substances (63.1%; 1780 cases). There were 885 (31.3%) cases that involved only cannabis, and 158 cases (5.6%) that related to cannabis edibles. The leading external cause of injury among children and adults was poisoning. A large proportion of cannabis-related cases were unintentional in nature, and time trend analyses revealed that cannabis-related cases have recently been increasing among both children and adults. Overall, 15.1% of cases involved serious injuries requiring admission to hospital.

CONCLUSION

Cannabis-related cases in the eCHIRPP database are relatively rate, a finding that may point to the fact that mental and behavioural disorders resulting from cannabis exposure are not generally captured in this surveillance system and the limited number of sites found across Canada. With Canada's recent amendments to cannabis regulations, ongoing surveillance of the health impacts of cannabis will be imperative to help advance evidence to protect the health of Canadians.

Frequent but limited assessment of potentially concussed players in Gaelic Football: an opportunity to learn from other sports

BACKGROUND

Sport-related concussion (SRC) is a potential issue within Gaelic Football. Therefore, it is essential that concussion management guidelines are adhered to.

HYPOTHESIS/PURPOSE

The aim of this study is to determine if potential concussive events (PCEs) in the Gaelic Athletic Association (GAA) National Football League (NFL) are assessed in accordance with GAA concussion guidelines and compare this to other sports.

METHODS

A descriptive video analysis approach was undertaken to identify PCEs throughout two seasons of play. Subsequent assessment, return to play (RTP) decisions, and signs of concussion were evaluated.

RESULTS

A total of 242 PCEs were identified over 111 matches. Most PCEs (87.2%, n = 211) were assessed by medical personnel. However, 187 (88.6%) of assessments were under 2 min in duration. Of the 242 PCEs, 189 (78.1%) returned to play after on-pitch assessment, and 12 (5.0%) were removed following a PCE. Sixty-one (25.2%) players sustaining a PCE demonstrated one or more signs of concussion, of which 9 (14.8%) were removed from play.

CONCLUSION

In the GAA NFL, PCEs are often briefly assessed but rarely result in player removal. Introduction of video incident analysis and concussion substitutions, as in other sports, may reduce the long-term burden of SRC on Gaelic Football players.

Equestrian Helmet Standards: Do They Represent Real-World Accident Conditions?

The use of helmets in equestrian sports has reduced the occurrence of traumatic brain injuries although, despite improvements to helmets, concussion remains a common injury. Currently, equestrian helmets are designed to pass certification standards involving a linear drop test to a rigid surface, while most concussions in equestrian sports result from oblique impacts to a compliant surface. The purpose of this study was to: (1) Compare the head kinematics and brain tissue response of the current equestrian helmet standard (EN1) and proposed standard EN13087-11 (EN2) to those associated with reconstructions of real-world equestrian concussion accidents. (2) Design a test protocol that would reflect the real-world conditions associated with concussion in equestrian sports. (3) To assess the protective capacity of an equestrian helmet using the flat turf and 45° turf proposed test protocols. Results for reconstructions of real-world concussions were obtained from a previous study (Clark et al. in J. Sci. Med. Sport 23:222-236, 2020). Using one jockey helmet model, impact tests were conducted according to the EN1 and EN2 protocols. Additionally, helmeted and unhelmeted tests were conducted at 5.9 and 6.0 m/s on to flat turf and 45° turf anvils for front, front-boss and rear-boss impact locations. The results demonstrated EN1 and EN2 both had higher magnitude accelerations and shorter duration impacts than reconstructed real-world concussive impacts. Impacts to turf anvils, on the other hand, produced similar head kinematics compared to the reconstructed real-world concussive impacts. Additionally, this study demonstrated that helmeted impacts significantly decreased rotational kinematics and brain tissue response below what is associated with unhelmeted impacts for oblique falls. However, the head kinematics and brain tissue response associated with these helmeted falls were consistent with concussion, suggesting that scope exists to improve the capacity of equestrian helmets to protect against concussion.

Professional assessment of potential concussions in elite football tournaments

Background

Potential concussive events (PCEs) are a major health concern in football. Though there are protocols set in place for assessments of PCEs, there has been no evidence of adherence in major football tournaments.

Methods

Our research goal is to determine if PCEs in elite football are professionally assessed according to the International Conference on Concussion in Sport (ICCS) consensus statement recommendations. Identification and analysis of PCEs in the 2018 World Cup (WC) were accomplished through standardised observation of video footage by trained observers. Results were contrasted with data from the 2014 WC and 2016 Euro Cup. Our primary outcomes include frequency and professional assessment of PCEs, signs of concussions and time stopped for assessments.

Findings

In the 64 games of the 2018 WC, 87 PCEs (1.36 per game) were identified. Thirty-one (35.6%) PCEs were professionally assessed, resulting in the removal of three (3.5%) players from the match. Six (6.9%) PCEs showed one sign of concussion, 60 (69.0%) showed two signs, 20 (23.0%) showed three signs and 1 (1.2%) showed four or more signs. The mean time stopped for assessment was 63.3 s. No significant change in the percentage of professional assessments (mean=33.4%, 95% CI 20.7% to 46.1%) were identified across tournaments (p=0.42).

Interpretation

These findings demonstrate a need for adherence to concussion protocols in order to improve the brain-health of athletes. Proper enforcement of the ICCS protocols during these tournaments and promoting player health and safety can influence the officiating, coaching and playing of football worldwide by promoting player safety.

Effects of a 6-Week Strength Training of the Neck Flexors and Extensors on the Head Acceleration during Headers in Soccer

The importance of well trained and stable neck flexors and extensors as well as trunk muscles for intentional headers in soccer is increasingly discussed. The neck flexors and extensors should ensure a coupling of trunk and head at the time of ball contact to increase the physical mass hitting the ball and reduce head acceleration. The aim of the study was to analyze the influence of a 6-week strength training program (neck flexors, neck extensors) on the acceleration of the head during standing, jumping and running headers as well as after fatigue of the trunk muscles on a pendulum header. A total of 33 active male soccer players (20.3 ± 3.6 years, 1.81 ± 0.07 m, 75.5 ± 8.3 kg) participated and formed two training intervention groups (IG1: independent adult team, IG2: independent youth team) and one control group (CG: players from different teams). The training intervention consisted of three exercises for the neck flexors and extensors. The training effects were verified by means of the isometric maximum voluntary contraction (IMVC) measured by a telemetric Noraxon DTS force sensor. The head acceleration during ball contact was determined using a telemetric Noraxon DTS 3D accelerometer. There was no significant change of the IMVC over time between the groups (F=2.265, p=.121). Head acceleration was not reduced significantly for standing (IG1 0.4 ± 2.0, IG2 0.1 ± 1.4, CG -0.4 ± 1.2; F = 0.796, p = 0.460), jumping (IG1-0.7 ± 1.4, IG2-0.2 ± 0.9, CG 0.1 ± 1.2; F = 1.272, p = 0.295) and running (IG1-1.0 ± 1.9, IG2-0.2 ± 1.4, CG -0.1 ± 1.6; F = 1.050, p = 0.362) headers as well as after fatigue of the trunk musculature for post-jumping (IG1-0.2 ± 2.1, IG2-0.6 ± 1.4; CG -0.6 ± 1.3; F = 0.184, p = 0.833) and post-running (IG1-0.3 ± 1.6, IG2-0.7 ± 1.2, CG 0.0 ± 1.4; F = 0.695, p = 0.507) headers over time between IG1, IG2 and CG. A 6-week strength training of the neck flexors and neck extensors could not show the presumed preventive benefit. Both the effects of a training intervention and the consequences of an effective intervention for the acceleration of the head while heading seem to be more complex than previously assumed and presumably only come into effect in case of strong impacts.

Medical assessment of potential concussion in elite football: video analysis of the 2016 UEFA European championship

OBJECTIVE

The objective is to determine if suspected concussions in elite football are medically assessed according to the International Conferences on Concussion in Sport consensus statement recommendations.

SETTING

Men's Union of European Football Association (UEFA) Football Championship.

PARTICIPANTS

All professional football players in the UEFA 2016 Championship Tournament.

DESIGN

Observational study.

OUTCOME MEASURES

Potential concussive events (PCEs) were defined as direct head collision incidents resulting in the athlete being unable to immediately resume play following impact. PCEs identified and description of PCE assessment and outcome were accomplished through direct standardised observation of video footage by trained observers in 51 games played in the Men's UEFA European Championship (10 June-10 July 2016).

RESULTS

Sixty-nine total PCEs (1.35 per match) were identified in 51 games played during the 2016 Men's UEFA European Championship. Forty-eight PCEs (69.6%) resulted in two observable signs of concussion, 13 (18.8%) resulted in three signs and 1 (1.4%) resulted in four signs in the injured athletes. Nineteen (27.5%) PCEs were medically assessed by sideline healthcare personnel while 50 (72.5%) were not. Of the 50 PCEs that were not medically assessed, 44 (88%) PCEs resulted in two or more signs of concussion among injured athletes. Of the 19 medically assessed PCEs, 8 resulted in 3 signs of concussion, and 1 resulted in 4 signs; all assessments concluded in the same-game return for the injured athletes.

CONCLUSIONS

PCEs were frequent events in the 2016 UEFA Euro championship, but were rarely assessed concordant with the International Conferences on Concussion in Sport consensus statement recommendations. There is an imperative need to improve the assessment and management of players suspected of concussion in elite football.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

The Influence of Fatigued Core Muscles on Head Acceleration during Headers in Soccer

The core muscles play a central role in stabilizing the head during headers in soccer. The objective of this study was to examine the influence of a fatigued core musculature on the acceleration of the head during jump headers and run headers. Acceleration of the head was measured in a pre-post-design in 68 soccer players (age: 21.5 ± 3.8 years, height: 180.0 ± 13.9 cm, weight: 76.9 ± 8.1 kg). Data were recorded by means of a telemetric 3D acceleration sensor and with a pendulum header. The treatment encompassed two exercises each for the ventral, lateral, and dorsal muscle chains. The acceleration of the head between pre- and post-test was reduced by 0.3 G (p = 0.011) in jump headers and by 0.2 G (p = 0.067) in run headers. An additional analysis of all pretests showed an increased acceleration in run headers when compared to stand headers (p < 0.001) and jump headers (p < 0.001). No differences were found in the sub-group comparisons: semi-professional vs. recreational players, offensive vs. defensive players. Based on the results, we conclude that the acceleration of the head after fatiguing the core muscles does not increase, which stands in contrast to postulated expectations. More tests with accelerated soccer balls are required for a conclusive statement.

Multiparametric MRI changes persist beyond recovery in concussed adolescent hockey players

OBJECTIVE

To determine whether multiparametric MRI data can provide insight into the acute and long-lasting neuronal sequelae after a concussion in adolescent athletes.

METHODS

Players were recruited from Bantam hockey leagues in which body checking is first introduced (male, age 11-14 years). Clinical measures, diffusion metrics, resting-state network and region-to-region functional connectivity patterns, and magnetic resonance spectroscopy absolute metabolite concentrations were analyzed from an independent, age-matched control group of hockey players (n = 26) and longitudinally in concussed athletes within 24 to 72 hours (n = 17) and 3 months (n = 14) after a diagnosed concussion.

RESULTS

There were diffusion abnormalities within multiple white matter tracts, functional hyperconnectivity, and decreases in choline 3 months after concussion. Tract-specific spatial statistics revealed a large region along the superior longitudinal fasciculus with the largest decreases in diffusivity measures, which significantly correlated with clinical deficits. This region also spatially intersected with probabilistic tracts connecting cortical regions where we found acute functional connectivity changes. Hyperconnectivity patterns at 3 months after concussion were present only in players with relatively less severe clinical outcomes, higher choline concentrations, and diffusivity indicative of relatively less axonal disruption.

CONCLUSIONS

Changes persisted well after players' clinical scores had returned to normal and they had been cleared to return to play. Ongoing white matter maturation may make adolescent athletes particularly vulnerable to brain injury, and they may require extended recovery periods. The consequences of early brain injury for ongoing brain development and risk of more serious conditions such as second impact syndrome or neural degenerative processes need to be elucidated.

Systematic Review of Traumatic Brain Injuries in Baseball and Softball: A Framework for Prevention

BACKGROUND

Traumatic brain injuries (TBIs) are an important public health challenge. The classification of baseball and softball as low contact sports and their association with extremity injuries cause individuals to overlook the risk of TBI in baseball and softball.

PURPOSE

To summarize our knowledge of the epidemiology and risk factors of TBIs associated with baseball and softball with an aim to better design and implement preventive strategies.

METHODS

A search algorithm containing keywords that were synonymous to the terms "TBI," "baseball" was applied to the following nine databases: MEDLINE, Scopus, PubMed, EMBASE, CINAHL, Healthstar, PsychINFO, AMED, Cochrane library. Cited reference lists of identified articles were also consulted yielding a total of eighty-eight articles for full review. The search was concluded on November 14, 2016. The level of evidence was evaluated according to the guidelines from Strengthening the Reporting of Observational Studies in Epidemiology statement.

RESULTS

Twenty-nine articles published between 2000 and 2016 met the criteria for analysis. Collectively, they examined the years 1982-2015 and identified 242,731 baseball-and softball-related TBIs. The most explored outcome of TBI was concussion. The average injury rate per 1,000 athletic exposures was 0.13 (range 0.03-0.46). The most common mechanism of injury was being struck by bat for younger players and being struck by ball for older athletes (adolescent and beyond). Rates of TBI were on average 4.17 times greater in games compared to practices. Females were on average 2.04 times more likely to sustain a TBI than males. Severity of TBIs varied considerably from mild and returning to the field on the same day, to immediate death. Generally, there is poor compliance with helmet use and return-to-play post-concussion guidelines. An increase TBI rates was observed over time. Multifaceted preventive strategies must be implemented to reduce the frequency and burden of these injuries.

CONCLUSION

It is difficult to compare the epidemiologic trends of TBI in baseball and softball due critical differences in the methods employed across the studies. Additional research is needed to provide a greater understanding of baseball- and softball-related TBI and to aid in the development of prevention and management modules.

Graded Aerobic Treadmill Testing in Adolescent Traumatic Brain Injury Patients

PURPOSE

To examine the safety and tolerability of clinical graded aerobic treadmill testing in recovering adolescent moderate and severe traumatic brain injury (TBI) patients referred to a multidisciplinary pediatric concussion program.

METHODS

We completed a retrospective case series of two moderate and five severe TBI patients (mean age, 17.3 years) who underwent initial Buffalo Concussion Treadmill Testing at a mean time of 71.6 days (range, 55-87) postinjury.

RESULTS

Six patients completed one graded aerobic treadmill test each and one patient underwent initial and repeat testing. There were no complications. Five initial treadmill tests were completely tolerated and allowed an accurate assessment of exercise tolerance. Two initial tests were terminated early by the treatment team because of neurological and cardiorespiratory limitations. As a result of testing, two patients were cleared for aerobic exercise as tolerated and four patients were treated with individually tailored submaximal aerobic exercise programs resulting in subjective improvement in residual symptoms and/or exercise tolerance. Repeat treadmill testing in one patient performed after 1 month of treatment with submaximal aerobic exercise prescription was suggestive of improved exercise tolerance. One patient was able to tolerate aerobic exercise following surgery for posterior glottic stenosis.

CONCLUSIONS

Preliminary results suggest that graded aerobic treadmill testing is a safe, well tolerated, and clinically useful tool to assess exercise tolerance in appropriately selected adolescent patients with TBI. Future prospective studies are needed to evaluate the effect of tailored submaximal aerobic exercise prescription on exercise tolerance and patient outcomes in recovering adolescent moderate and severe TBI patients.

Legislation for Youth Sport Concussion in Canada: Review, Conceptual Framework, and Recommendations

In this article, we conduct a review of introduced and enacted youth concussion legislation in Canada and present a conceptual framework and recommendations for future youth sport concussion laws. We conducted online searches of federal, provincial, and territorial legislatures to identify youth concussion bills that were introduced or successfully enacted into law. Internet searches were carried out from July 26 and 27, 2016. Online searches identified six youth concussion bills that were introduced in provincial legislatures, including two in Ontario and Nova Scotia and one each in British Columbia and Quebec. One of these bills (Ontario Bill 149, Rowan's Law Advisory Committee Act, 2016) was enacted into provincial law; it is not actual concussion legislation, but rather a framework for possible enactment of legislation. Two bills have been introduced in federal parliament but neither bill has been enacted into law. At present, there is no provincial or federal concussion legislation that directly legislates concussion education, prevention, management, or policy in youth sports in Canada. The conceptual framework and recommendations presented here should be used to guide the design and implementation of future youth sport concussion laws in Canada.

Lack of eye discipline during headers in high school girls soccer: A possible mechanism for increased concussion rates

The sport of soccer is the fastest growing and most popular sport worldwide. With this growth and popularity, attention needs to be given to this athletic population. Sports related concussions is a topic that has gained attention both in the media and by governmental organizations, with growing initiatives in diagnosis, prevention and treatment. The act of soccer heading is thought to contribute to increased concussion incidence. Current evidence reveals that within the high school soccer athletic population, female athletes incur a higher concussion rate than males. This is often attributed to many things including differing cervical spinal musculature, skull thickness, etc., but a definitive reason has not yet been found. Other behaviors, such as field awareness and eye discipline™ on the field of play, may also be contributing factors that result in females incurring a greater concussion rate than males. For the purposes of this paper we define eye discipline™ as the ability to keep the eyes engaged in sporting activity with high risk potential. We present our hypothesis that high school female soccer players are more likely to have their eyes closed when in position for heading the ball as compared to high school male soccer players and this lack of visual awareness may increase the risk of concussion. Should these differences be substantiated between males and females, it may initiate and promote discussion of the need for vision training in the high school athletic setting. As a tool for injury prevention, vision training may improve specific visual parameters improving athletes' abilities to process the field of play and prepare for or avoid injury causing situations. Through ocular motor and visual conditioning, an athlete may become more eye disciplined™, and more likely to have their eyes open during heading of the ball, and more likely to avoid concussions.

Multidisciplinary Management of Pediatric Sports-Related Concussion

Objectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.

Realistically furthering the goals of public health by cannabis legalization with strict regulation: Response to Kalant

Cannabis Policy Framework respond to select issues from Kalant's Commentary (in this issue).

Retirement-from-sport considerations following pediatric sports-related concussion: case illustrations and institutional approach

The decision to advise an athlete to retire from sports following sports-related concussion (SRC) remains a persistent challenge for physicians. In the absence of strong empirical evidence to support recommendations, clinical decision making must be individualized and should involve a multidisciplinary team of experts in concussion and traumatic brain injury. Although previous authors have advocated for a more conservative approach to these issues in child and adolescent athletes, there are few reports outlining considerations for this process among this unique population. Here, the authors use multiple case illustrations to discuss 3 subgroups of clinical considerations for sports retirement among pediatric SRC patients including the following: those with structural brain abnormalities identified on neuroimaging, those presenting with focal neurological deficits and abnormalities on physical examination, and those in whom the cumulative or prolonged effects of concussion are suspected or demonstrated. The authors' evolving multidisciplinary institutional approach to return-to-play and retirement decision making in pediatric SRC is also presented.

A human factors approach to snowsport safety: Novel research on pediatric participants' behaviors and head injury risk

OBJECTIVE

This study applied a human factors approach to snowsport resort systems to contribute to the understanding of the incidence and severity of pediatric snowsport head accelerations.

BACKGROUND

Previous research indicates low magnitude head accelerations are common among snowsport participants. This study adds to the knowledge of snowsport safety by measuring aspects of participants' snowsport behavior and linking this with head acceleration data.

METHOD

School-aged students (n = 107) wore telemetry-fitted helmets and Global Positioning System (GPS) devices during snowsport activity. Data was collected over 159 sessions (total hours 701). Head accelerations recorded by the telemetry units were compared with GPS-generated data.

RESULTS

This study found speeds attained normally exceed the testing rating for which helmets are designed; lower rates of head accelerations compared to earlier studies and that when head accelerations did occur they were generally below the threshold for concussions.

CONCLUSION

Pediatric snowsport head accelerations are rare and are generally of low magnitude. Those most at risk of a head acceleration >40 g were male snowboarders. Given the recorded speeds in first time participants, increased targeting of novice snowsport participants to encourage education about the use of protective equipment, including helmets, is warranted. Post event recall was not a good indicator of having experienced a head impact. Consideration should be given to raising the standard design speed testing for snowsport helmet protective devices to reflect actual snowsport behaviors.

A prospective surveillance of paediatric head injuries in Singapore: a dual-centre study

OBJECTIVE

To study the causes of head injuries among the paediatric population in Singapore, and the association between causes and mortality, as well as the need for airway or neurosurgical intervention.

DESIGN

This is a prospective observational study utilising data from the trauma surveillance system from January 2011 to March 2015.

SETTING

Paediatric emergency departments (EDs) of KK Women's and Children's Hospital and the National University Health System.

PARTICIPANTS

We included children aged <16 years presenting to the paediatric EDs with head injuries who required a CT scan, admission for monitoring of persistent symptoms, or who died from the head injury. We excluded children who presented with minor mechanisms and those whose symptoms had spontaneously resolved.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary composite outcome was defined as death or the need for intubation or neurosurgical intervention. Secondary outcomes included length of hospital stay and type of neurosurgical intervention.

RESULTS

We analysed 1049 children who met the inclusion criteria. The mean age was 6.7 (SD 5.2) years. 260 (24.8%) had a positive finding on CT. 17 (1.6%) children died, 52 (5.0%) required emergency intubation in the ED and 58 (5.5%) underwent neurosurgery. The main causes associated with severe outcomes were motor vehicle crashes (OR 7.2, 95% CI 4.3 to 12.0) and non-accidental trauma (OR 5.8, 95% CI 1.8 to 18.6). This remained statistically significant when we stratified to children aged <2 years and performed a multivariable analysis adjusting for age and location of injury. For motor vehicle crashes, less than half of the children were using restraints.

CONCLUSIONS

Motor vehicle crashes and non-accidental trauma causes are particularly associated with poor outcomes among children with paediatric head injury. Continued vigilance and compliance with injury prevention initiatives and legislature are vital.

Health & Economic Burden of Traumatic Brain Injury in the Emergency Department

Objective:To evaluate epidemiological patterns and lifetime costs of traumatic brain injury (TBI) identified in the emergency department (ED) within a publicly insured population in Ontario, Canada, in 2009.Methods:A nationally representative, population-based database was used to identify TBI cases presenting to Ontario EDs between April 2009 and March 2010. We calculated unit costs for medical treatment and productivity loss, and multiplied these by corresponding incidence estimates to determine the lifetime costs of identified TBI cases across age group, sex, and mechanism of injury.Results:In 2009, there were more than 133,000 ED visits for TBI in Ontario, resulting in a conservative estimate of $945 million in lifetime costs. Lifetime cost estimates ranged from $279 million to $1.22 billion depending on the diagnostic criteria used to define TBI. Peak rates of TBI occurred among young children (ages 0-4 year) and the elderly (ages 85+ years). Males experienced a 53% greater rate of TBI and incurred two-fold higher costs compared with females. Falls, sports/bicyclist-related injuries, and motor vehicle crashes represented 47%, 12%, and 10% of TBI presenting to ED, respectively, and accounted for a significant proportion of costs.Conclusions:This study revealed an enormous health and economic burden associated with TBI identified in the ED setting. Our findings underscore the importance of ongoing surveillance and prevention efforts targeted to vulnerable populations. More research is needed to fully appreciate the burden of TBI across a variety of health care settings.

Recognizing the Symptoms of Mental Illness following Concussions in the Sports Community: A Need for Improvement

OBJECTIVE

To evaluate the awareness of concussion-related symptoms amongst members of the sports community in Canada.

METHODS

A cross-sectional national electronic survey was conducted. Youth athletes, parents, coaches and medical professionals across Canada were recruited through mailing lists from sports-related opt-in marketing databases. Participants were asked to identify, from a list of options, the symptoms of a concussion. The proportion of identified symptoms (categorized as physical, cognitive, mental health-related and overall) as well as participant factors associated with symptom recognition were analyzed.

RESULTS

The survey elicited 6,937 responses. Most of the respondents (92.1%) completed the English language survey, were male (57.7%), 35-54 years of age (61.7%), with post-secondary education (58.2%), or high reported yearly household income (>$80,000; 53.0%). There were respondents from all provinces and territories with the majority of respondents from Ontario (35.2%) or British Columbia (19.1%). While participants identified most of the physical (mean = 84.2% of symptoms) and cognitive (mean = 91.2% of symptoms), they on average only identified 53.5% of the mental health-related symptoms of concussions. Respondents who were older, with higher education and household income, or resided in the Northwest Territories or Alberta identified significantly more of the mental health-related symptoms listed.

INTERPRETATION

While Canadian youth athletes, parents, coaches and medical professionals are able to identify most of the physical and cognitive symptoms associated with concussion, identification of mental health-related symptoms of concussion is still lagging.

Managing mass events and competitions with difficult-to-access locations using mobile electrocardiac monitoring

OBJECTIVE

Using mobile wireless technology to monitor ECG in participants of mass events and sports taking place in difficult-to-access location could both prevent and easier detect arrhythmias as well as provide real-time monitoring for any type of injury. We assessed the effectiveness of mobile wireless monitoring technology and IT in detecting possible emergencies during a skyscraper race.

METHODS

We attached specially designed wireless surveillance biopatches on 120 individuals participating to monitor their continuous ECG and location during a skyscraper run-up race at Taipei 101 building, Taiwan. The outcomes of interest were detection of abnormal heartbeats and QRS waves indicative of possible cardiac problems and the exact location of participants during the occurrence of emergencies.

RESULTS

The devices accurately sent over 50 warnings to our monitoring platform when both, danger limits were reached by competitors (<60 or >195 beats per minute) or competitors stopped moving, proving very effective in quickly detecting abnormities and alerting staff of possible emergencies at exact locations.

CONCLUSION

This efficient and inexpensive monitoring method can also prevent arrhythmias in unscreened competitors, the danger of collision among staff and competitors, and preserves oxygen by eliminating additional on-foot monitoring staff. Additionally, it could have multipurpose usage, especially during disasters and accidents occurring in difficult-to-access locations, in military exercises and personal monitoring.

A systematic review and meta-analysis of concussion in rugby union

BACKGROUND

Rugby Union, a popular full-contact sport played throughout the world, has one of the highest rates of concussion of all full-contact sports.

OBJECTIVE

The aim of the current review was to systematically evaluate the available evidence on concussion in Rugby Union and to conduct a meta-analysis of findings regarding the incidence of concussion.

METHODS

Articles were retrieved via a number of online databases. The current review examined all articles published in English up to May 2014 pertaining to concussion in Rugby Union players. The key search terms included 'Rugby Union', 'rugby', 'union', and 'football', in combination with the injury terms 'athletic injuries', 'concussion', 'sports concussion', 'sports-related concussion', 'brain concussion', 'brain injury', 'brain injuries', 'mild traumatic brain injury', 'mTBI', 'traumatic brain injury', 'TBI', 'craniocerebral trauma', 'head injury', and 'brain damage'.

RESULTS

The final search outcome following the eligibility screening process resulted in the inclusion of 96 articles for this review. The meta-analysis included a total of 37 studies. The results of the meta-analysis revealed an overall incidence of match-play concussion in men's rugby-15s of 4.73 per 1,000 player match hours. The incidence of concussion during training was 0.07 per 1,000 practice hours. The incidence of concussion in women's rugby-15s was 0.55 per 1,000 player match hours. In men's rugby-7s match-play, concussion incidence was 3.01 per 1,000 player match hours. The incidence of concussion varied considerably between levels of play, with elite level play recording a rate of 0.40 concussions per 1,000 player match hours, schoolboy level 0.62 concussions per 1,000 player match hours, and the community or sub-elite level recording a rate of 2.08 concussions per 1,000 player match hours. The incidence of concussion in men's rugby-15s as a function of playing position (forwards vs. backs) was 4.02 and 4.85 concussions per 1,000 player match hours, respectively.

CONCLUSIONS

Concussion is a common injury sustained and reported in match play and to a lesser extent during practice by Rugby Union players. Based on the available published data, there appears to be a variation in risk of concussion across level of play, with the sub-elite level having the greatest incidence of injury. Future research focused on studying the acute consequences and best management strategies in current players, and the potential longer term outcomes of concussion in retired players, is needed. A focus on the areas of prevention, injury identification, and medical management, and risk for long-term outcomes will be of benefit to current athletes.

A Retrospective Evaluation of Pediatric Major Trauma Related to Sport and Recreational Activities in Nova Scotia

OBJECTIVES

A small proportion of pediatric sport- and recreation-related injuries are serious enough to be considered "major trauma." However, the immediate and long-term consequences in cases of pediatric major trauma are significant and potentially life-threatening. The objective of this study was to describe the incidence and outcomes of pediatric major traumas related to sport and recreational activities in Nova Scotia.

METHODS

This study was a retrospective case series. Data on major pediatric traumas related to sport and recreational activities on a provincial scope were extracted from the Nova Scotia Trauma Program Registry between 2000 and 2013. We evaluated frequency, type, severity, and outcomes of major traumas. Outcomes assessed included length of hospital stay, admission to a special care unit (SCU), and mortality.

RESULTS

Overall, 107 children aged three to 18 years sustained a major trauma (mean age 12.5 [SD 3.8]; 84% male). Most injuries were blunt traumas (97%). The greatest proportion were from cycling (59, 53%), followed by hockey (8, 7%), skateboarding (7, 7%) and skiing (7, 7%). The Nova Scotia Pediatric Trauma Team was activated in 27% of cases. Mean in-hospital length of stay was five days (SD 5.6), and nearly half (49%) of patients required SCU admission. Severe traumatic brain injury occurred in 52% of cases, and mortality in five cases.

CONCLUSIONS

Over a 13-year period, the highest incidence of pediatric major trauma related to sport and recreational activities was from cycling, followed by hockey. Severe traumatic brain injury occurred in over half of pediatric major trauma patients.

Animal models of sports-related head injury: bridging the gap between pre-clinical research and clinical reality

Sports-related head impact and injury has become a very highly contentious public health and medico-legal issue. Near-daily news accounts describe the travails of concussed athletes as they struggle with depression, sleep disorders, mood swings, and cognitive problems. Some of these individuals have developed chronic traumatic encephalopathy, a progressive and debilitating neurodegenerative disorder. Animal models have always been an integral part of the study of traumatic brain injury in humans but, historically, they have concentrated on acute, severe brain injuries. This review will describe a small number of new and emerging animal models of sports-related head injury that have the potential to increase our understanding of how multiple mild head impacts, starting in adolescence, can have serious psychiatric, cognitive and histopathological outcomes much later in life. Sports-related head injury (SRHI) has emerged as a significant public health issue as athletes can develop psychiatric and neurodegenerative disorders later in life. Animal models have always been an integral part of the study of human TBI but few existing methods are valid for studying SRHI. In this review, we propose criteria for effective animal models of SRHI. Movement of the head upon impact is judged to be of primary importance in leading to concussion and persistent CNS dysfunction.

Concussions and heading in soccer: a review of the evidence of incidence, mechanisms, biomarkers and neurocognitive outcomes

BACKGROUND

Soccer is currently the most popular and fastest-growing sport worldwide. Similar to many sports, soccer carries an inherent risk of injury, including concussion. Soccer is also unique in the use of 'heading'. The present paper provides a comprehensive review of the research examining the incidence, mechanisms, biomarkers of injury and neurocognitive outcomes of concussions and heading in soccer.

METHODS

Seven databases were searched for articles from 1806 to 24 May 2013. Articles obtained by the electronic search were reviewed for relevance, with 229 selected for review. Ultimately, 49 articles met criteria for inclusion in the present review.

RESULTS

Female soccer players have a higher incidence of concussions than males. The most frequent injury mechanism is player-to-player contact for both genders. Few studies examined the effects of concussion in soccer players; however, neurocognitive outcomes were similar to those reported in the larger sport concussion literature, while the effect of heading is less clear.

CONCLUSION

Despite variation in research designs and study characteristics, the outcomes of concussions in soccer align with the greater concussion literature. This review makes recommendations for future research to increase standardization of research for improved understanding of concussions in soccer as well as the effects of heading.