The initial visibility of updated recommendations on preseason heat safety in high school athletics among United States athletic trainers

Updated recommendations on preseason heat safety in high school (HS) athletics (“2021 Consensus Statements”) were published in April 2021. This cross-sectional survey study explored the initial roll-out of the 2021 Consensus Statements, including their visibility among United States HS athletic trainers (ATs) and perceived levels of confidence in implementing them. Recruitment occurred first, from a random selection of ATs from the Board of Certification, Inc., and second, an open invitation via social media. An online cross-sectional questionnaire had participating ATs note whether they had seen the 2021 Consensus Statements. If yes, ATs reported their perceived level of confidence in implementing them (5-point-ordinal scale from “not at all confident” to “very confident); if no, ATs disclosed (open-ended) why they had not yet seen them. Descriptive statistics were calculated for quantitative variables; template analysis identified codes related to visibility of and confidence in implementing 2021 Consensus Statements. Nearly half (45.7%) of 116 responding HS ATs reported having seen at least one 2021 Consensus Statements; 23.3% had reviewed all three. Common reasons among the 63 that had not seen them included: not aware they were published (n = 22), have yet to read them (n = 19), and believed they could not access the journal (n = 10). Of the 53 ATs having seen at least one of the 2021 Consensus Statements, 67.9% (n = 36) were very/fairly confident in implementing them at their HS. Reasons for confidence included their schools ensuring up-to-date EHI prevention and management practices (n = 18) and athletics constituent support (n = 8). This exploratory study observed proportions of surveyed HS ATs that had not seen the 2021 Consensus Statements and were not confident in implementing them. Findings highlight the need to continue improving messaging about access to best-practice recommendations. Further, continued efforts inclusive of active and passive dissemination strategies across all athletics constituents are needed to aid proper implementation

Demographic, parental, and personal factors and youth athletes' concussion-related knowledge and beliefs

Context: Currently, significant attention is focused on improving care for patients with concussions through legislative mandates that include educational interventions. Few researchers have examined young athletes' concussion knowledge and the factors that may influence their knowledge. Objective: To use the socioecological model to examine demographic, parental, and personal factors associated with youth athletes' knowledge of concussion. Our ultimate goal is to inform the planning and implementation of youth sport concussion-related interventions. Design: Cross-sectional survey. Setting: Gymnasium and classroom. Patients or Other Participants: North Carolina and Arizona youth athletes (n ¼ 225; age ¼ 8 to 15 years) active in football, boys' or girls' soccer, boys' or girls' ice hockey, or boys' or girls' lacrosse in 2012-2013. Main Outcome Measure(s): Participants completed a validated, self-administered survey. The intention and belief measures were guided by the theory of planned behavior. Perceptions of concussion and intention to seek care were examined using descriptive statistics. Athletes' concussion knowledge was modeled using linear regressions and generalized estimating equations, with child demographic and personal factors and parental knowledge and attitudes about concussion as predictors. Results: Geography, sport, parental attitudes toward concussion, and athlete age were associated with athlete knowledge in the univariable analyses (P, .10). In the multivariable model, geographic location (North Carolina versus Arizona, mean difference [MD] ¼ 2.2, 95% confidence interval [CI] ¼ 1.1, 3.2), sport (girls' soccer versus girls' lacrosse, MD ¼ 2.2, 95% CI ¼ 0.7, 3.6), more favorable parental attitudes toward concussion (MD ¼ 1.2 for a 2-standard deviation shift; 95% CI ¼ 0.3, 2.1), and older age (.12 years, MD ¼ 1.6; 95% CI ¼ 0.5, 2.6) were associated with better knowledge about concussion. Conclusions: Geographic location, sport, parental attitudes about concussion, and athlete's age influenced athletes' concussion-related perceptions, indicating the need to address multiple levels of the socioecological model when targeting youth sport interventions. Parental interventions that translate to an improved culture of youth sport by improving youth athletes' perceptions and experiences are key areas for future work

Randomized controlled trial evaluating aerobic training and common sport-related concussion outcomes in healthy participants

Context: Aerobic exercise interventions are increasingly being prescribed for concussion rehabilitation, but whether aerobic training protocols influence clinical concussion diagnosis and management assessments is unknown. Objective: To investigate the effects of a brief aerobic exercise intervention on clinical concussion outcomes in healthy, active participants. Design: Randomized controlled clinical trial. Setting: Laboratory. Patients or Other Participants: Healthy (uninjured) participants (n ¼ 40) who exercised 3 times/week. Intervention(s): Participants were randomized into the acute concussion therapy intervention (ACTIVE) training or nontraining group. All participants completed symptom, cognitive, balance, and vision assessments during 2 test sessions approximately 14 days apart. Participants randomized to ACTIVE training completed six 30-minute exercise sessions that progressed from 60% to 80% of individualized maximal oxygen consumption (Vo2max) across test sessions, while the nontraining group received no intervention. Main Outcome Measure(s): The CNS Vital Signs standardized scores, Vestibular/Ocular Motor Screening near-point convergence distance (cm), and Graded Symptom Checklist, Balance Error Scoring System, and Standardized Assessment of Concussion total scores. Results: An interaction effect was found for total symptom score (P ¼ .01); the intervention group had improved symptom scores between sessions (session 1: 5.1 6 5.8; session 2: 1.9 6 3.6). Cognitive flexibility, executive functioning, reasoning, and total symptom score outcomes were better but composite memory, verbal memory, and near-point convergence distance scores were worse at the second session (all P values, .05). However, few changes exceeded the 80% reliable change indices calculated for this study, and effect sizes were generally small to negligible. Conclusions: A brief aerobic training protocol had few meaningful effects on clinical concussion assessment in healthy participants, suggesting that current concussion-diagnostic and -assessment tools remain clinically stable in response to aerobic exercise training. This provides normative data for future researchers, who should further evaluate the effect of ACTIVE training on clinical outcomes among concussed populations

A randomized controlled trial investigating the feasibility and adherence to an aerobic training program in healthy individuals

Context: Concussion management is moving from passive rest strategies to active interventions, including aerobic exercise therapy. Little information is available regarding the feasibility and adherence of these programs. Objectives: To determine whether an aerobic exercise training program intended for rehabilitation in people with concussion is feasible. Healthy, nonconcussed subjects were studied in this phase 1 trial. Design: Phase 1 parallel-group, randomized controlled trial in a sample of healthy (nonconcussed), recreationally active university students. Setting: Laboratory. Patients: 40 healthy university students. Methods: Participants were equally randomized to acute concussion therapy intervention (ACTIVE) training or nontraining groups. All participants completed maximal cardiopulmonary exercise tests on a stationary cycle ergometer at 2 test sessions approximately 14 days apart. During this 2-week study period, ACTIVE training participants completed six 30-minute cycling sessions, progressing from 60% to 80% of the participant's individualized maximal oxygen consumption. A subset of participants (NACTIVE = 12, Nnontraining = 11) wore physical activity monitors throughout the 2-week study period. Main Outcomes Measures: Study protocol and randomization effectiveness, exercise safety and adherence, and progressive intensity of the ACTIVE training procedures. Results: No adverse events occurred during any exercise sessions. Twelve ACTIVE training participants (60%) completed all training sessions, and every participant completed at least 4 sessions. Heart rate increased throughout the training period (P < .001), but symptom changes and training adherence remained stable despite the progressively increasing workload. ACTIVE training participants completed approximately 30 additional minutes of physical activity on training sessions days, although that was not statistically significant (P = .20). Conclusions: University-aged students were adherent to the ACTIVE training protocol. Future research should investigate the safety and feasibility of aerobic training programs in acutely concussed individuals to determine their appropriateness as a clinical rehabilitation strategy

Relationship between concussion history and concussion knowledge, attitudes, and disclosure behavior in high school athletes

Objective: Examine the association between self-reported concussion history and measures of concussion knowledge, attitude, and disclosure behavior. Design: Cross-sectional survey. Setting: Classroom. Participants: A convenience sample of high school athletes (n = 167; mean age = 15.7 years) from multiple sports completed a validated survey. Independent Variables: Concussion history (main predictor) was defined as the number of self-recalled concussions during participants' high school career. Main Outcome Measures: The outcomes were recalled concussion disclosure behavior (3 measures) and scales assessing both concussion knowledge and concussion attitude. Results: A greater number of previous concussions was associated with worse attitude to concussion and negative concussion disclosure behavior. For every 3 additional self-recalled concussions, there was a mean decrease of 7.2 points (range of possible scores = 14-98) in concussion attitude score (P = 0.002), a 48% decrease in the self-reported proportion of concussion events disclosed (P = 0.013), and an increased prevalence of self-reported participation in games (67%) and practices (125%) while experiencing signs and symptoms of concussion (P < 0.001). Increased concussion history did not affect concussion knowledge score (P = 0.333). Conclusions: Negative trends in concussion disclosure behavior were identified in youth athletes with a positive history of concussion. Improving disclosure in this subgroup will require targeted efforts addressing negative attitude to concussion

Understanding Youth Sport Coaches' Perceptions of Evidence-Based Injury-Prevention Training Programs: A Systematic Literature Review

Objective: To systematically review and summarize the knowledge, attitudes, beliefs, and contextual perceptions of youth sport coaches toward injury-prevention training programs by using the Theoretical Domains Framework to guide the organization of results. Data Sources: Systematic searches of PubMed and Google Scholar were undertaken in November 2021. Study Selection: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was followed. Results were limited to full-text articles that were published in peer-reviewed journals and printed in English. Additional studies were added after a citation search of included studies. Studies were eligible for inclusion if researchers evaluated youth sport coaches' knowledge, beliefs, contextual perceptions, or all 3 of anterior cruciate ligament injury-prevention training programs. Data Extraction: Data charting was performed by 1 author and confirmed by a separate author. Data Synthesis: Of the 1194 articles identified, 19 were included in the final sample. Among articles in which researchers assessed knowledge (n = 19), coaches' awareness of the existence and components of injury-prevention training programs was inconsistent. Among articles in which researchers assessed beliefs (n = 19), many coaches had positive attitudes toward injury-prevention training programs, but few believed youth athletes are at a high risk of injury. Among articles in which researchers assessed contextual perceptions (n = 13), many coaches did not feel they had access to information about injuryprevention training programs and cited a lack of time, space, support, and other resources as barriers to implementation. Conclusions: Our findings support the need for programs, protocols, and policies to enhance knowledge of and support for youth sport coaches who wish to implement injury-prevention training programs. A gap exists in the research about addressing the needs of youth sport coaches in the United States high school sports setting. The use of multilevel implementation science frameworks (such as the Theoretical Domains Framework) will be beneficial for identifying constructs that affect implementation and developing train-the-trainer programming to meet the needs of individual youth sport coaches

Concussion Nondisclosure During Professional Career Among a Cohort of Former National Football League Athletes

Background: Despite a focus on the incidence and effects of concussion, nondisclosure of sports-related concussions among retired players from the National Football League (NFL) has yet to be examined. Purpose: Examine the prevalence of and factors associated with nondisclosure of sports-related concussions in former NFL athletes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A sample of 829 former NFL players completed a general health survey. This historical cohort included players who had played before World War II to 2001. Respondents retrospectively recalled sports-related concussions that they sustained during their professional careers and whether at least one of these sports-related concussions was not reported to medical staff. We computed the prevalence of nondisclosure among those recalling sport-related concussions during their professional careers. Multivariable binomial regression estimated adjusted prevalence ratios (PR) with 95% confidence intervals (CIs) controlling for race/ethnicity, number of years played, primary position played, professional career concussion history, and playing era. Playing era was categorized by whether the majority of a player’s career was before or after a 1976 rule change to limit contact (“spearing”). Results: Overall, 417 (50.3%) respondents reported they had sustained a concussion and did not inform medical staff at least once during their professional playing career. Nonwhite respondents had a higher prevalence of nondisclosure than white/non-Hispanic respondents (adjusted PR = 1.19; 95% CI, 1.02-1.38). An interaction between professional career concussion history and playing era was also found (P =.08). Compared with those in the pre–spearing rule change group with 1 or 2 concussions, all other groups had larger prevalences of nondisclosure (increases ranging from 41% to 153% in multivariable models). Across concussion strata, nondisclosure prevalence was generally higher in the post–spearing rule change group than the pre–spearing rule change group, with the largest differences found among those with 1 or 2 concussions or those with 3 or 4 concussions. Conclusion: A large proportion of former NFL players in this historical cohort reported at least one instance of not disclosing sports-related concussions to medical staff. Future research on concussion nondisclosure needs to identify mechanisms to improve football players’ intentions to disclose concussion-related symptoms to health care providers and to equip health care providers with more effective strategies for timely identification of concussion

Association between Sensation-Seeking Behaviors and Concussion-Related Knowledge, Attitudes, Perceived Norms, and Care-Seeking Behaviors among Collegiate Student-Athletes

There are limited data connecting personality and behavioral tendencies and traits related to concussion care-seeking/disclosure behaviors and minimal research exists surrounding the relationship between risky behaviors, sensation-seeking, and concussion-related outcomes. This study examined the association between sensation-seeking and a student-athlete’s concussion-related knowledge, attitudes, perceived social norms, and concussion care-seeking/disclosure behaviors (intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury). The current study utilized a retrospective cohort of collegiate student-athletes at a single National Collegiate Athletic Association Division I institution. Separate multivariable linear regression models estimating mean differences (MD) and 95% Confidence Intervals (CI) estimated the association between sensation-seeking and concussion knowledge, concussion attitudes, and perceived social norms. Separate multivariable binomial regression models estimating adjusted prevalence ratios (PR) and 95%CI estimated the association between sensation-seeking and intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury. All models were adjusted for sex, sport participation, and concussion history. Higher sensation-seeking was significantly associated with less favorable concussion attitudes (adjusted MD = 1.93; 95%CI =-3.04,-0.83), less favorable perceived social norms surrounding concussion (adjusted MD =-1.39; 95%CI =-2.06,0.72), and continuing to play while experiencing concussion symptoms (adjusted PR = 1.50; 95%CI = 1.10, 2.06). Studentathletes with increased sensation-seeking could be at risk for failing to disclose a concussion, decreasing athlete safety and resulting in less optimal care post-injury. Results will inform future theory-based concussion education programs which consider behavioral tendencies and traits as well as sport culture to promote concussion care-seeking/disclosure and individualized interventions based on risky behavior engagement

Estimating Concussion Incidence Using Sports Injury Surveillance Systems: Complexities and Potential Pitfalls

Numerous sports injury surveillance systems exist with the capability of tracking concussion incidence data. It is important for the consumers of sport-related concussion data, be they researchers or the public, to have a comprehensive understanding of the strengths and limitations of sports injury surveillance systems. This article discusses issues of system design and analysis that affect the interpretation and understanding of sport-related concussion incidence data from sports injury surveillance systems. Such understanding will help inform the design of sports injury surveillance systems and research studies that aim to identify risk factors, develop prevention strategies, and evaluate prevention mechanisms

Sport culture and communication among middle school athletes, parents, and staff: A qualitative study

Middle school (MS) is an intermediary level of education between elementary and secondary school that typically includes students aged 10–15 years. There is limited research within the MS sport setting, particularly related to sport-related injury prevention. This qualitative study aimed to better understand the sport culture within MS sports and the communication strategies used among invested groups (i.e., athletes, parents, staff inclusive of coaches and school nurses). Semi-structured interviews were conducted with 19 athletes, 20 parents, and 18 staff (e.g., coaches, school nurses) from seven MS in two school districts during the 2018/19 and 2019/20 school years. Topics focused on understanding school- and sport-related factors related to education, safety, and communication. Analysis used a consensual qualitative research tradition, in which the research team discussed individually developed themes and categories from transcribed interviews, with the goal of coming to a consensus and creating a codebook. Throughout the coding process, the research team would reconvene to discuss coding decisions until consensus was reached. This study focuses on the themes of sport culture and communication. Dominant categories identified within sport culture related to participants noting why they were interested in MS sports, and their struggles with their perceived roles and engagement (e.g., helping parents stay engaged, finding coaches, oversight of school nurses). Competitiveness and safety could have conflicting roles and priority. Dominant categories identified within communication centered around limited communication between coaches and parents. Technological assistance (e.g., phone apps, websites) was available, but often varied by school and sport. Concussions were seldom discussed unless during the preseason meeting or when one occurred. Findings highlight that the MS sport settings may struggle with incorporating primary prevention into their cultures and ensuring reliable communication among individuals. Novel and tailored approaches to injury prevention are needed to help ensure buy-in and proper implementation