Publications by authors named "Emily Kroshus"

80 Publications

The Association Between School Closures and Child Mental Health During COVID-19.

JAMA Netw Open 2021 09 1;4(9):e2124092. Epub 2021 Sep 1.

Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, Washington.

Importance: In-person schooling has been disrupted for most school-aged youth during the COVID-19 pandemic, with low-income, Black, and Hispanic populations most likely to receive fully remote instruction. Disruptions to in-person schooling may have negatively and inequitably affected children's mental health.

Objective: To estimate the association between school closures and child mental health outcomes and how it varies across sociodemographic factors.

Design, Setting, And Participants: This cross-sectional population-based survey study included a nationally representative sample of US adults aged 18 to 64 years with at least 1 child in the household. The survey was administered between December 2 and December 21, 2020, via web and telephone in English and Spanish. Participants were recruited from the NORC AmeriSpeak panel, an address-based panel with known probability sampling and coverage of 97% of US households.

Exposures: Schooling modality (in person, fully remote, or hybrid), household income, age.

Main Outcomes And Measures: Child mental health difficulties were measured with the parent-report version of the Strengths and Difficulties Questionnaire, with small, medium, and large effect sizes defined as 1.3-, 3.3-, and 5.2-point differences, respectively.

Results: A total of 2324 adults completed the survey. Overall, 1671 respondents (71.9%) were women, 244 (10.5%) were Black, 372 (16.0%) were Hispanic, and 421 (18.1%) had a high school education or less. Children attending school in-person had higher household incomes (mean difference, $9719; 95% CI, $4327 to $15 111; P < .001) and were more likely to be White compared with those attending remotely (366 of 556 [65.8%] vs 597 of 1340 [44.5%]; P < .001). Older children in remote schooling had more mental health difficulties than those attending in-person schooling (standardized effect size, 0.23 [95% CI, 0.07 to 0.39] per year older; P = .006), corresponding to small effect sizes in favor of in-person schooling for older children and very small effect sizes favoring remote schooling for younger children. Children from families with higher income benefitted more from attending schools in-person compared with their peers from families with lower income (B = -0.20 [95% CI, -0.10 to -0.30] per $10 000-increase in annual income; P < .001), although this advantage was not apparent for children attending hybrid school (B = -0.05 [95% CI, -0.16 to 0.06] per $10 000-increase in annual income; P = .34), and directionally lower but not significantly different for children attending remote school (B = -0.12 [95% CI, -0.04 to -0.20] per $10 000-increase in annual income; P < .001). Learning pods fully buffered the associations of hybrid schooling (d = -0.25; 95% CI, -0.47 to -0.04) but not remote schooling (d = 0.04; 95% CI, -0.10 to 0.18) with negative mental health outcomes.

Conclusions And Relevance: The findings of this study suggest that older and Black and Hispanic children as well as those from families with lower income who attend school remotely may experience greater impairment to mental health than their younger, White, and higher-income counterparts. Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and workforce augmentation, during and beyond the COVID-19 pandemic.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.24092DOI Listing
September 2021

Developing a conceptual model of coach concussion communication by adapting the theory of planned behavior and the social ecological model.

J Am Coll Health 2021 Aug 16:1-8. Epub 2021 Aug 16.

The Center on Brain Injury Research and Training, University of Oregon, Eugene, OR, USA.

: Acknowledging that coach communication about concussion increases the likelihood of athletes reporting concussive symptoms, the goal of this study was to examine factors affecting such communication, in order to develop a conceptual model that would inform the design of future educational interventions.: Division I contact sport coaches.: We conducted structured qualitative interviews with coaches and analyzed interviews using Thematic Analysis, viewed through the lens of the Theory of Planned Behavior nested within the Social Ecological Model.: Coaches had good knowledge of concussion and understood the dangers of playing with symptoms. However, they also discussed the lack of objective criteria for concussion diagnosis, and pressure to win in order to remain employed, both of which created barriers to concussion communication. Ultimately, most coaches reported not engaging in significant concussion communication as they did not feel this was their role, instead deferring to medical staff.: Educational interventions might benefit from a focus on the importance of coach concussion safety-supportive coach communication, with a goal of increasing the likelihood of athlete concussion reporting.
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http://dx.doi.org/10.1080/07448481.2021.1944166DOI Listing
August 2021

Socioeconomic Inequities in Youth Participation in Physical Activity and Sports.

Int J Environ Res Public Health 2021 06 29;18(13). Epub 2021 Jun 29.

Center for Leadership in Athletics, University of Washington, Seattle, WA 98195, USA.

Access to opportunities for physical activity and sports, and therefore potential benefits of participation, are distributed inequitably. The aims of this study were to describe and compare youth experiences related to sport and physical activity by socioeconomic factors. A cross-sectional survey was conducted of students in 5-12th grades in King County, Washington, USA. Students were asked about physical activity and sports experiences and about demographic factors including family affluence, which was categorized as low, medium, and high. Participants were 1038 youth (50% girls, 58% non-White, and 32% from homes where languages other than English are spoken). Children from low-affluence families reported fewer days/week of physical activity, fewer sports sampled, and lower rates of ever playing sports. Greater proportions of children from low-affluence families reported these barriers to sports: (1) don't want to get hurt, (2) don't feel welcome on teams, (3) too expensive, and (4) transportation. Middle school children from high-affluence families had three times higher odds of meeting physical activity recommendations, and high-affluence high schoolers had three times higher odds of ever participating in sports compared to peers from low-affluence families. Socioeconomic status was inversely associated with outcomes related to youth physical activity and sports participation. The disproportionately reported barriers to sports participation are modifiable, and cross-sector solutions can help promote play equity.
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http://dx.doi.org/10.3390/ijerph18136946DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8297079PMC
June 2021

Factors Influencing College Football Players' Beliefs About Incurring Football-Related Dementia.

Orthop J Sports Med 2021 Apr 28;9(4):23259671211001129. Epub 2021 Apr 28.

Department of Pediatrics, University of Washington, Seattle, Washington, USA.

Background: Football participation is associated with risks to acute and long-term health, including the possibility of incurring football-related dementia. Concerns have been raised regarding media coverage of these risks, which may have influenced athletes' beliefs. However, little is known about football players' views on football-related dementia. The risk-perception literature suggests that related risk perceptions and features of individual cognition, such as the ability to switch to reasoned, deliberative thinking, may influence individual perception of a long-term risk.

Purpose: To evaluate factors influencing college football players' belief that they are likely to incur football-related dementia in the future.

Study Design: Cross-sectional study.

Methods: Members of 4 National Collegiate Athletic Association Division I Power 5 Football teams participated in this survey-based study, providing responses to demographic, athletic, and risk-posture questions, and completed the cognitive reflection test. Logistic regressions were used to evaluate relationships between beliefs about football-related dementia and factors including athletic and demographic characteristics, football risk posture, health-risk posture, and cognitive reflection test score.

Results: About 10% of the 296 participating athletes thought football-related dementia was likely to occur in their future. Skill players had lower odds than linemen of believing that football-related dementia was likely (odds ratio [OR], 0.35; 95% CI, 0.14-0.89). For each additional suspected concussion in an athlete's career, his odds of believing football-related dementia was likely increased by 24% (OR, 1.24; 95% CI, 1.07-1.45). Acute and chronic football-related risk perceptions, as well as non-football-related health-risk perceptions, were positively associated with athletes' belief that football-related dementia was likely. Higher cognitive reflection test scores, a measure of ability to switch to slow, deliberative thinking, was positively associated with odds of believing football-related dementia was likely (OR, 1.57; 95% CI, 1.12-2.21).

Conclusion: Some athletes view football as generally riskier, while others view football as generally lessri sky. These risk postures are informed by athletes' concussion history, primary playing position, and ability to switch from fast, reactive thinking to slow, deliberative thinking. Ensuring that athletes are appropriately informed of the risks of participation is an ethical obligation of universities; sports medicine clinicians are appropriate facilitators of conversations about athletes' health risks.
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http://dx.doi.org/10.1177/23259671211001129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107942PMC
April 2021

Family Media Use Planning With Teens-Is It Time for Shared Decision-making?

JAMA Pediatr 2021 Apr;175(4):349-350

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington.

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http://dx.doi.org/10.1001/jamapediatrics.2020.5637DOI Listing
April 2021

Accuracy of US College Football Players' Estimates of Their Risk of Concussion or Injury.

JAMA Netw Open 2020 12 1;3(12):e2031509. Epub 2020 Dec 1.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Importance: Despite increased concern about the health consequences of contact sports, little is known about athletes' understanding of their own risk of sports-related injury.

Objective: To assess whether college football players accurately estimate their risk of concussion and nonconcussion injury and to identify characteristics of athletes who misestimate their injury risk.

Design, Setting, And Participants: In this survey study, questionnaires were given to 296 current college football players on 4 teams from the 3 of the 5 most competitive conferences of the US National Collegiate Athletic Association. Surveys were conducted between February and May 2017. Data were analyzed from June 2017 through July 2020.

Main Outcomes And Measures: Multiple approaches were taken to compare athlete perceptions of their risks of concussion and nonconcussion injury with individual probabilities of these risks, which were modeled using logistic regression.

Results: Of 296 male college-aged athletes from 4 football teams who participated in the survey, 265 (89%) answered all questions relevant for this study. Participating teams were similar to nonparticipating teams across nearly all measured characteristics. One hundred athletes (34%) had sustained 1 or more concussions, and 197 (68% of the 289 who responded to the question) had sustained 1 or more injuries in the previous football season. Logistic regression models of single-season injury and concussion had reasonably good fit (area under the curve, 0.75 and 0.73, respectively). Of the 265 participants for whom all relevant data were available, 111 (42%) underestimated their risk of concussion (χ2 = 98.6; P = .003). A similar proportion of athletes (113 [43%]) underestimated their risk of injury, although this was not statistically significant (χ2 = 34.0; P = .09). An alternative analytic strategy suggested that 241 athletes (91%) underestimated their risk of injury (Wilcoxon statistic, 7865; P < .001) and 167 (63%) underestimated their risk of concussion (Wilcoxon statistic, 26 768; P < .001).

Conclusions And Relevance: The findings of this survey study suggest that college football players may underestimate their risk of injury and concussion. The implications for informed participation in sport are unclear given that people generally underestimate health risks. It is necessary to consider whether athletes are sufficiently informed and how much risk is acceptable for an athlete to participate in a sport.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.31509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772718PMC
December 2020

Stress, self-compassion, and well-being during the transition to college.

Soc Sci Med 2021 01 10;269:113514. Epub 2020 Nov 10.

University of Washington, School of Medicine & College of Education, USA.

Rationale: The transition to college presents a period of vulnerability to mental illness, and opportunity for positive psychosocial development.

Objective: The present study sought to build an explanatory person-centered and contextualized model of student wellbeing in the transition to college.

Method: Participants were entering first year undergraduate students at a large public university in the United States (n = 5509). Online survey data were collected at three time points across the academic year, with outcomes of depression and anxiety, thriving, and grade point average, and predictors including resilient coping, self-compassion, social support, school connections and the acute and chronic stressors experienced during the transition to college. Latent growth curves were used to examine trajectories of change in depression and anxiety, and a cross-lagged panel model was used to describe a system of how all measured variables influenced each other over time.

Results: There were four main findings. On average, students experienced moderate increases in depression and anxiety from the summer before college through the spring, with wide variability across students and no clear patterning by demographic groups. Second, self-compassion was the strongest and most consistent predictor of successful transitions. Third, chronic stressors were strongly predictive of more negative outcomes, and self-compassion and coping skills did not buffer their effects. Finally, people most likely to experience chronic stressors over the school year included women, people who identify as sexual minorities and first-generation students.

Conclusions: Programming to support entering college students should seek to foster self-compassion, while also limiting chronic stressors and reducing their inequitable distribution across the student population.
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http://dx.doi.org/10.1016/j.socscimed.2020.113514DOI Listing
January 2021

Improving Concussion Education: Consensus From the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge.

J Spec Oper Med 2020 ;20(3):88-95

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and MSA settings with a priori thresholds for retaining, discarding, and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and MSA cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes, and (5) organizational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioral health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.
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November 2020

Community-Engaged Approach to the Development and Implementation of a Student-Centered Return to Learn Care Plan After Concussion.

J Sch Health 2020 11 21;90(11):842-848. Epub 2020 Sep 21.

University of Washington, Seattle, WA, 98104.

Background: Current return to learn (RTL) after concussion guidelines lack specificity for individualized student care, limiting potential for adoption and implementation. We used a community-engaged research framework to develop and evaluate the implementation of a student-centered care plan that assists school personnel in facilitating RTL.

Methods: We used best-practice RTL guidelines and input from administrators and medical experts to iteratively develop a flexible student-centered care plan. Thirteen schools participated. Coding completion of care plans indicated feasibility and fidelity; interviews with RTL coordinators indicated acceptability.

Results: The care plan includes educational materials, symptom checklists, and guidelines for classroom adjustments linked to student symptoms. Care plans were initiated for 24 (70.6%) of 34 students with concussions, indicating feasibility. Fidelity was high, with the following subsections completed: Action Checklist (90%), Symptom Evaluation (91%), Temporary Adjustment Recommendations (95%). Qualitative analysis of interviews suggested care plans were acceptable and facilitate consistent communication, prioritization of individual needs of students, and increased ability to delegate tasks to other school staff.

Conclusions: Implementation of a student-centered, individually tailored care plan for RTL is feasible and acceptable in public high schools. Future research should examine how to expediently initiate student-centered concussion care plans after diagnosis to optimize recovery.
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http://dx.doi.org/10.1111/josh.12948DOI Listing
November 2020

International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes' mental health.

Br J Sports Med 2021 Jan 18;55(1):30-37. Epub 2020 Sep 18.

Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland.

Objectives: To develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders.

Methods: We conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool. SPORT MENTAL HEALTH ASSESSMENT TOOL 1 AND SPORT MENTAL HEALTH RECOGNITION TOOL 1: The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches).

Conclusion: The SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment.
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http://dx.doi.org/10.1136/bjsports-2020-102411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788187PMC
January 2021

Parent influence on concussion reporting in first-year collegiate athletes.

J Am Coll Health 2020 Sep 14:1-10. Epub 2020 Sep 14.

Department of Exercise Science, Elon University, Elon, North Carolina, USA.

Objective: To assess the relationship between sport-parenting practices and concussion reporting intentions of collegiate athletes across two levels of competition.

Participants: Entering first-year student-athletes (varsity and club) at a mid-sized university in the Southeast region of the United States (n = 327).

Methods: Written surveys were completed prior to the start of the 2015 academic year. Structural equation modeling was used to test a model predicting concussion-reporting intentions.

Results: College athletes were more likely to intend to report a suspected concussion when they believed their parents wanted them to report (B=-0.88, SD = 0.94), and when they experienced less sport achievement pressure from their parents (B=-0.12, SD = 8.07).

Conclusions: Parents influence the concussion safety of entering collegiate athletes at both the varsity and club level. Lower pressure sport parenting prior to college entry may help foster safer concussion reporting behaviors and may be an appropriate target for future intervention development work.
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http://dx.doi.org/10.1080/07448481.2020.1809430DOI Listing
September 2020

Improving concussion education: consensus from the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge.

Br J Sports Med 2020 Nov 10;54(22):1314-1320. Epub 2020 Sep 10.

National Collegiate Athletic Association, Indianapolis, Indiana, USA.

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and military service academy settings with a priori thresholds for retaining, discarding and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and military service academy cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes and (5) organisational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioural health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.
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http://dx.doi.org/10.1136/bjsports-2020-102185DOI Listing
November 2020

Plans of US Parents Regarding School Attendance for Their Children in the Fall of 2020: A National Survey.

JAMA Pediatr 2020 Aug 14. Epub 2020 Aug 14.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington.

Importance: As schools consider reopening for in-person instruction prior to availability of a coronavirus disease 2019 (COVID-19) vaccine, families may be weighing their priorities regarding school attendance.

Objective: To characterize the association of planned in-person school attendance during the COVID-19 pandemic with factors, including family socioeconomic characteristics, and parent attitudes and beliefs about their child's school attendance.

Design, Setting, And Participants: Cross-sectional survey study. Data were collected from June 2, 2020, to June 5, 2020, weighted to reflect population norms, and analyzed using ordered probit regression. A sample of US parents (of children ages 5-17 years) were recruited using a nonprobability survey panel with stratification by socioeconomic characteristics.

Main Outcomes And Measures: The main outcome was parent-reported plan to send their child to school or keep their child home, conditional on their school opening for in-person instruction. Additional measures assessed family socioeconomic characteristics, medical vulnerability, worry about COVID-19 and multisystem inflammatory syndrome, confidence in their child's school, and homeschooling difficulties.

Results: The sample of 730 parents was balanced by parent sex (53% women) with successful oversampling for Black (28%; n = 201) and Hispanic (27%; n = 200) participants. In estimates weighted to US population norms, 31% (95% CI, 27% to 34%) of participants indicated they would probably or definitely keep their child home this fall, and 49% indicated that they would probably or definitely send their child to school this fall. Factors associated with planning to keep children home included lower income (38% with incomes <$50 000 vs 21% with incomes $100 000-$150 000 per year; difference, 17%; 95% CI, 9% to 26%), being unemployed (40% unemployed vs 26% employed; difference, 14%; 95% CI, 5% to 25%), and having a flexible job (33% with flexible jobs vs 19% with inflexible jobs; difference, 14%; 95% CI, 5% to 30%). Planning to keep children home was also associated with fear of COVID-19 (B = 0.19; P < .001), fear of multisystem inflammatory syndrome (B = 0.12; P = .04), confidence in schools (B = -0.22; P < .001), and challenges of homeschooling (B = -0.12; P = .01). Race and ethnicity were not significantly associated with plans to keep children home.

Conclusions And Relevance: In this survey study, many parents planned to keep children home in fall 2020. Schools need to act soon to address parental concerns and provide options for what will be available for them should they opt to keep their child home. Structural barriers, such as lack of workplace flexibility and potential school-level inequities in implementation of preventive measures, must be acknowledged and addressed where possible.
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http://dx.doi.org/10.1001/jamapediatrics.2020.3864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428818PMC
August 2020

Understanding Decision Making by Families About Youth Football Participation Postconcussion.

Health Promot Pract 2020 Jul 30:1524839920945255. Epub 2020 Jul 30.

University of Washington, Seattle, WA, USA.

Many families are concerned about their child's risk of concussion, and some seek counsel from clinicians about whether or not to return to contact sports participation postinjury. The present study sought to identify factors that parents weight most heavily in forming their preferences regarding whether their child should return to contact sport after recovering from a concussion. Survey data were collected from 568 parents of youth football players (aged 7-14 years) in the Pacific Northwest region of the United States (73% response rate). Approximately two thirds (63%) of parents preferred that their child retire from football after one or two concussions. Multivariable linear regression indicated parents above the sample mean in terms of how strongly they valued football participation preferred their child stop after more concussions than parents below the sample mean (β = .44, standard error [ = 0.06, < .001). Factors endorsed by the most parents as making them "much more likely" to want their child to stop playing football included the belief that their child will experience cognitive issues later in life as a result of concussions (65.0%) and that their child will get another concussion while playing football (43.5%). Within the context of a clinical visit postconcussion, physicians may need to help families clarify their values related to football participation and provide information about the potential outcomes of returning to contact sport. A formalized shared decision aid could help support consistent implementation of this potentially challenging conversation.
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http://dx.doi.org/10.1177/1524839920945255DOI Listing
July 2020

Trust, Conflicts of Interest, and Concussion Reporting in College Football Players.

J Law Med Ethics 2020 06;48(2):307-314

Christine M. Baugh, Ph.D., M.P.H., is an Assistant Professor of Medicine in the Division of General Internal Medicine at the University of Colorado and Core Research Faculty at the Center for Bioethics and Humanities at the University of Colorado. She received a Doctor of Philosophy (Ph.D.) in Health Policy and Bioethics from Harvard University (Cambridge, MA), a Master's Degree in Public Health (M.P.H.) concentrating in Health Law, Bioethics, and Human Rights from Boston University School of Public Health (Boston, MA) and a Bachelor of Arts (B.A.) in history and science from Harvard University (Cambridge, MA). Emily Kroshus, Sc.D., M.P.H., is a Research Assistant Professor at University of Washington in the Department of Pediatrics, based at the Seattle Children's Research Institute in the Center for Child Health, Behavior and Development. She received her Doctor of Science (Sc.D.) from Harvard University's School of Public Health in the Department of Social and Behavioral Sciences, where she also received a certificate in Health Communication (Boston, MA). She has a master's degree in public health (M.P.H.) from Johns Hopkins University's Bloomberg School of Public Health (Baltimore, MD), and a bachelor of arts (B.A.) degree in economics from Princeton University (Princeton, NJ). William P. Meehan III, M.D., is an Associate Professor of Pediatrics and Orthopedics at Harvard Medical School, Director of the Micheli Center for Sports Injury Prevention, and Director of Research for the Brain Injury Center at Boston Children's Hospital. He received his medical doctorate (M.D.) from Harvard Medical School (Boston, MA) and his bachelor of arts (B.A.) from Boston College (Boston, MA). Eric G. Campbell, Ph.D., is a Professor of Medicine in the Division of General Internal Medicine at the University of Colorado and Director of Research at the Center for Bioethics and Humanities at the University of Colorado. He received his Doctor of Philosophy (Ph.D.) in Higher Educational Policy and Administration from the University of Minnesota (Minneapolis, MN), his Masters of Arts (M.A.) in Education from the University of Minnesota (Minneapolis, MN), and his Bachelor of Arts (B.A.) in Psychology from the University of Minnesota (Minneapolis, MN).

Sports medicine clinicians face conflicts of interest in providing medical care to athletes. Using a survey of college football players, this study evaluates whether athletes are aware of these conflicts of interest, whether these conflicts affect athlete trust in their health care providers, or whether conflicts or athletes' trust in stakeholders are associated with athletes' injury reporting behaviors.
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http://dx.doi.org/10.1177/1073110520935342DOI Listing
June 2020

Student awareness of campus medical amnesty policies.

J Am Coll Health 2020 Jun 4:1-8. Epub 2020 Jun 4.

Institute to Promote Athlete Health & Wellness, Department of Public Health Education, The University of North Carolina Greensboro, Greensboro, North Carolina, USA.

Examine students' awareness of medical amnesty policies and the influence of policy awareness on the expected consequences of bystander help seeking in alcohol-related emergencies among student-athletes and non-athletes. 1,012 college students. Spearman's correlation and chi-square tests were used to examine accuracy in awareness of amnesty policies. Nominal logistic regression was used to test the relationship between amnesty policy awareness and expected consequences of bystander help seeking. About 25% of students were unsure if their school had an amnesty policy; of these students, 67% attended schools with such a policy. Students who were unsure about the presence of amnesty policies were more likely to expect serious negative consequences of calling for help for both non-athlete peers (B = 1.152  < 0.001) and student-athlete peers (B = 0.887  = 0.001). Greater attention is needed to how amnesty policies are implemented on college campuses, including how they are communicated to and interpreted by student-athletes.
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http://dx.doi.org/10.1080/07448481.2020.1767112DOI Listing
June 2020

Sports Medicine Staffing Patterns and Incidence of Injury in Collegiate Men's Ice Hockey.

J Athl Train 2020 Jun;55(6):587-593

Division of Sports Medicine, Sports Concussion Clinic, Boston Children's Hospital, MA.

Context: The relative availability of clinicians as well as the types and training of health care providers have been associated with morbidity and mortality in non-athletic health care settings. Whether staffing variations are associated with injury incidence in collegiate athletes is unknown.

Objective: To evaluate whether the institutional ratio of athletes to athletic trainers (patient load) or the ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers or both is associated with the incidence of injuries sustained by male ice hockey athletes at the school.

Design: Descriptive epidemiology study.

Setting: National Collegiate Athletic Association (NCAA) men's ice hockey teams.

Patients Or Other Participants: Collegiate men's ice hockey athletes.

Main Outcome Measure(s): The NCAA Injury Surveillance Program collected data from collegiate men's ice hockey athletes. Staffing patterns were obtained through telephone interviews. Injury counts, injury rates per 1000 athlete-exposures, and injury rate ratios with 95% confidence intervals were calculated and compared between the following groups: (1) schools with high (versus low) patient load and (2) schools with high (versus low) ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers.

Results: Both the patient load and relative number of staff athletic trainers were associated with variations in the incidences and types of diagnosed injuries in male ice hockey players. Specifically, fewer injuries were diagnosed by clinicians at institutions with high patient loads. The rates of injury overall and non-time-loss injuries were lower in the high patient-load group. Time-loss injury rates, severe injury rates, concussion rates, and overall rates of injury during competition were greater in the group with a higher proportion of staff athletic trainers, whereas non-time-loss injury rates were lower.

Conclusions: In this study of collegiate men's ice hockey players, athlete health outcomes were directly related to the number and types of clinicians available. Future researchers should evaluate whether this finding extends beyond men's ice hockey.
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http://dx.doi.org/10.4085/1062-6050-0464.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319740PMC
June 2020

Sports Medicine Staffing Across National Collegiate Athletic Association Division I, II, and III Schools: Evidence for the Medical Model.

J Athl Train 2020 Jun;55(6):573-579

Division of Sports Medicine, Sports Concussion Clinic, Boston Children's Hospital, MA. Dr Baugh is now at the Center for Bioethics and Humanities, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora.

Context: The ratio of clinicians to patients has been associated with health outcomes in many medical contexts but has not been explored in collegiate sports medicine. The relationship between administrative and financial oversight models and staffing is also unknown.

Objective: To (1) evaluate staffing patterns in National Collegiate Athletic Association sports medicine programs and (2) investigate whether staffing was associated with the division of competition, Power 5 conference status, administrative reporting structure (medical or athletic department), or financial structure (medical or athletic department).

Design: Cross-sectional study.

Setting: Collegiate sports medicine programs.

Patients Or Other Participants: Representatives of 325 universities.

Main Outcome Measure(s): A telephone survey was conducted during June and July 2015. Participants were asked questions regarding the presence and full-time equivalence of the health care providers on their sports medicine staff. The number of athletes per athletic trainer was determined.

Results: Responding sports medicine programs had 0.5 to 20 full-time equivalent staff athletic trainers (median = 4). Staff athletic trainers at participating schools cared for 21 to 525 athletes per clinician (median = 100). Both administrative and financial oversight from a medical department versus the athletics department was associated with improved staffing across multiple metrics. Staffing levels were associated with the division of competition; athletic trainers at Division I schools cared for fewer athletes than athletic trainers at Division II or III schools, on average. The support of graduate assistant and certified intern athletic trainers varied across the sample as did the contributions of nonphysician, nonathletic trainer health care providers.

Conclusions: In many health care settings, clinician : patient ratios are associated with patient health outcomes. We found systematic variations in clinician : patient ratios across National Collegiate Athletic Association divisions of competition and across medical versus athletics organizational models, raising the possibility that athletes' health outcomes vary across these contexts. Future researchers should evaluate the relationships between clinician : patient ratios and athletes' access to care, care provision, health care costs, health outcomes, and clinician job satisfaction.
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http://dx.doi.org/10.4085/1062-6050-0463-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319741PMC
June 2020

Content analysis of concussion education for coaches of youth and high school sport.

Brain Inj 2020 06 2;34(7):905-913. Epub 2020 May 2.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute , Seattle, Washington, USA.

Objective: Describe the extent to which concussion education provided to coaches of US high school and youth sport is inclusive of information necessary for them to engage in target behaviors related to the prevention, identification and management of concussion.

Methods: Sport organizations included in the sample were US state high school governing bodies and national governing bodies (NGBs) for youth sports with the highest concussion incidence rates. The concussion education resources made available online for coaches by these organizations were coded for content relevant to concussion prevention, identification and management.

Results: All but one state high school governing body required coach concussion education, two NGBs required coach education, seven recommended it and only one did not require or recommend it. All educational materials covered at least 84% (n = 16/19) of the relevant knowledge domains.

Discussion: Existing concussion education for coaches is addressing most, but not all, topics that may help coaches engage in concussion prevention, identification and management. Additional program development work is warranted to augment educational content related to coach communication about concussion safety with athletes and parents. Content appropriateness notwithstanding, further research is needed to understand the acceptability, efficacy, and implementation of concussion education for coaches.
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http://dx.doi.org/10.1080/02699052.2020.1755894DOI Listing
June 2020

Social support during youth concussion recovery.

Brain Inj 2020 05 21;34(6):782-790. Epub 2020 Apr 21.

Concussion Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, Canada.

Purpose: We explored the lived experience of high-school aged girls receiving social support during concussion recovery to better understand (1) how they define meaningful social support and barriers/facilitators to receiving it; (2) who provides that support; and (3) the role of peers.

Methods: In person, semi-structured interviews were conducted with 10 girls (aged 14-19 years) with a personal history of concussion.

Results: Close friends, youth with personal history of concussion, and parents were identified as key providers of meaningful social support during concussion recovery. Participants identified specific examples of support provided by each group. Close friends built a sense of social inclusion that mitigated feelings of social isolation. Youth with a personal history of concussion used their lived experiences to communicate empathy and validate the participant's challenges. Parents assisted with practical challenges (e.g. accessing accommodations) by leveraging their "adult power". Participants identified that lack of understanding of their lived experiences was a key barrier to receiving support. They proposed solutions focused on education initiatives highlighting personal accounts from youth with concussion, and specific examples of how peers can help.

Conclusions: Fostering social support may require strategies tailored to each group of key providers as they mitigate different challenges in recovery.
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http://dx.doi.org/10.1080/02699052.2020.1753243DOI Listing
May 2020

Determining the role of sport coaches in promoting athlete mental health: a narrative review and Delphi approach.

BMJ Open Sport Exerc Med 2020 27;6(1):e000676. Epub 2020 Jan 27.

Institute to Promote Athlete Health and Wellness, University of North Carolina at Greensboro, Greensboro, North Carolina, USA.

Background: Coaches have the potential to support athlete mental wellness, but many are unsure what to do and concerned they may unintentionally engage in behaviours that negatively impact their athletes. Education has the potential to help coaches engage in primary, secondary and tertiary preventive behaviours related to athlete mental health; however, there exists no empirical or consensus basis for specifying the target behaviours that should be included in such education.

Objective: The aim of this research was to review extant literature about the role of sport coaches in mental health prevention and promotion, and obtain expert consensus about useful, appropriate and feasible coach behaviours.

Design: Modified Delphi methodology with exploration (ie, narrative review) and evaluation phase.

Data Sources: Twenty-one articles from PubMed, PsycINFO and ProQuest, and grey literature published by prominent sport organisations.

Eligibility Criteria For Selecting Studies: All studies were English-language articles that focused on the role of coaches as they relate to (1) culture setting in sport, (2) addressing athlete mental health and (3) providing ongoing support to athletes with mental health concerns. No study design, publication date limits or sport characteristics were applied.

Results: The coach's role should include fostering team cultures that support athlete mental health, encouraging care-seeking and supporting athletes currently receiving mental healthcare.

Summary/conclusion: The behaviours specified herein have implications for coach education programme development. This study is the first to use a structured Delphi process to develop specific recommendations about the role coaches can play in supporting athlete mental health.
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http://dx.doi.org/10.1136/bmjsem-2019-000676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011013PMC
January 2020

Direct Verbal Communication by Parents, Pressure Related to Sport Achievement, and Concussion Safety in Youth Football.

J Health Commun 2019 31;24(10):770-779. Epub 2019 Oct 31.

Department of Pediatrics, University of Washington, Seattle, Washington, USA.

Direct verbal communication from parents about concussion safety and parent pressure related to sport achievement may influence concussion risk-related behavior among youth athletes. This study assessed whether less parental pressure related to sport achievement and more parental communication about concussion safety were associated with lower intentions to continue sport participation while experiencing concussion symptoms. Participants were youth football players (ages 10-14) and their parents (n = 278 dyads, response rate = 45%). Structural equation modeling was used to predict the athlete's intention to continue play with concussive symptoms. One quarter of parents had never talked with their child about any concussion safety topic, and more than half had not talked about concussion safety within the past year. Greater parent communication about concussion and less pressure on sport achievement were both associated with lower child intention to continue playing while symptomatic post-concussion. Parents who placed more pressure on their child related to sport achievement were less likely to talk about concussion safety with their child. Determining how to shape parenting that is supportive of concussion safety is an important avenue for future health education program development work. This may include efforts to parenting behaviors in the sport context that reinforce effort rather than winning.
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http://dx.doi.org/10.1080/10810730.2019.1668512DOI Listing
September 2020

Randomized Evaluation of the National Collegiate Athletic Association's Concussion Education Fact Sheet for Coaches.

Health Educ Behav 2019 12 30;46(6):960-968. Epub 2019 Sep 30.

National Collegiate Athletic Association, Indianapolis, IN, USA.

. Concussion education for coaches is being increasingly recommended by leading sports organizations, yet the effectiveness of available materials has not often been assessed. This study evaluated the impact of the National Collegiate Athletic Association's (2017) publication: "Concussion safety: What coaches need to know" (the "NCAA Fact Sheet for Coaches") on participants' concussion knowledge and safety supportive intentions. . NCAA head coaches ( = 779) were randomized to view the NCAA Fact Sheet for Coaches either before (intervention condition) or after (control condition) responding to questions assessing concussion knowledge and intentions to engage in three behaviors (talk to team about concussion safety; allow symptomatic athlete to continue play; encourage medical staff to return athlete as quickly as possible). . Knowledge scores were significantly higher among coaches in the intervention condition as compared to the control condition, largely driven by differences in knowledge about the consequences of continued play postconcussion (injury, reaction time, possible death). Fewer coaches in the intervention condition expected that they would allow an athlete with a suspected concussion continue to participate in a game or practice or that they would encourage medical staff to return athletes to play as quickly as possible. . The present study provides evidence that educational content, like that contained in the NCAA Fact Sheet for Coaches, may have a positive short-term impact on concussion knowledge and behavioral intentions of coaches. In light of these findings, sports organizations should consider providing similar educational materials to coaches, evaluating whether the information is impactful in their population.
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http://dx.doi.org/10.1177/1090198119864621DOI Listing
December 2019

A New Game Plan for Concussion Education.

Health Educ Behav 2019 12 11;46(6):916-921. Epub 2019 Jul 11.

Seattle Children's Research Institute, Seattle, WA, USA.

Despite state laws requiring concussion education for youth sport stakeholders and a proliferation of educational programs, there has been little demonstrated impact on concussion reporting behaviors. We propose that this is because of four key limitations to existing approaches to concussion education: (1) deliberative decision making by the injured athlete is assumed, (2) interventions are often targeted at individuals rather than social systems, (3) education occurs once during preseason and is forgotten, and (4) dissemination challenges exacerbate health inequalities. Addressing these limitations, we propose a novel theoretic framework that situates individual behavior within a sport system's culture and their broader structural context. Concussion education programs should seek to facilitate safety-supportive interpersonal communication within and between stakeholder groups and influence attributes of groups that drive behavior, including shared values. Addressing the limitations outlined and drawing on the proposed conceptual framework, we describe a novel approach to concussion education: pregame safety huddles.
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http://dx.doi.org/10.1177/1090198119859414DOI Listing
December 2019

Implementation and effect of concussion education in collegiate women's ice hockey.

Phys Sportsmed 2020 02 3;48(1):46-52. Epub 2019 Jun 3.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

: This study aimed to determine whether collegiate women's ice hockey players are receiving pre-season concussion education and evaluate the nature and delivery of this education. Secondarily, we aimed to assess whether players who recall receiving this education have greater knowledge about concussion or are more likely to have reported suspected concussions than their peers.: An anonymous survey was completed by 459 NCAA women's ice hockey players. Players self-reported receipt of pre-season concussion education, year in school, division of competition, player position, and average length of ice hockey career. Players also completed scales assessing concussion knowledge, attitudes and prior reporting behavior for suspected concussions.: 65.3% of athletes affirmed that they received pre-season concussion education. Lecture by an athletic trainer was the most common modality. There were no differences in concussion knowledge or attitudes by concussion education status, NCAA division of competition, or year in school. Players with higher knowledge scores were more likely than their peers to have experienced a suspected concussion and to have not reported it (p = 0.056).: Not all NCAA women's ice hockey players are receiving (or recall receiving) mandated concussion education from their institution. The inverse association between concussion knowledge and concussion reporting behavior, while not statistically significant, is concerning and warrants further study. More work is needed to develop educational materials about concussion that are acceptable and memorable to this population, and that help increase concussion care-seeking behaviors.
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http://dx.doi.org/10.1080/00913847.2019.1624657DOI Listing
February 2020

Wake up call for collegiate athlete sleep: narrative review and consensus recommendations from the NCAA Interassociation Task Force on Sleep and Wellness.

Br J Sports Med 2019 Jun 16;53(12):731-736. Epub 2019 May 16.

National Collegiate Athletic Association, Indianapolis, Indiana, USA.

Sleep is an important determinant of collegiate athlete health, well-being and performance. However, collegiate athlete social and physical environments are often not conducive to obtaining restorative sleep. Traditionally, sleep has not been a primary focus of collegiate athletic training and is neglected due to competing academic, athletic and social demands. Collegiate athletics departments are well positioned to facilitate better sleep culture for their athletes. Recognising the lack of evidence-based or consensus-based guidelines for sleep management and restorative sleep for collegiate athletes, the National Collegiate Athletic Association hosted a sleep summit in 2017. Members of the Interassociation Task Force on Sleep and Wellness reviewed current data related to collegiate athlete sleep and aimed to develop consensus recommendations on sleep management and restorative sleep using the Delphi method. In this paper, we provide a narrative review of four topics central to collegiate athlete sleep: (1) sleep patterns and disorders among collegiate athletes; (2) sleep and optimal functioning among athletes; (3) screening, tracking and assessment of athlete sleep; and (4) interventions to improve sleep. We also present five consensus recommendations for colleges to improve their athletes' sleep.
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http://dx.doi.org/10.1136/bjsports-2019-100590DOI Listing
June 2019

Parents' Perspectives Regarding Age Restrictions for Tackling in Youth Football.

Pediatrics 2019 05 1;143(5). Epub 2019 Apr 1.

Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Departments of.

Background: In ice hockey and soccer, age restrictions exist for body checking and heading because of injury risk. There are currently no age restrictions for tackling in youth football.

Methods: We surveyed a nationally representative sample of US parents regarding their support for age restrictions on tackling in football with responses of "yes," "no," and "maybe." We then generated regression models, attempting to predict support for age restrictions in tackling using demographic variables, parent perceptions of the risk of concussion in youth football, and the intensity of football support. All analyses were stratified by sex given effect modification.

Results: There were 1025 parents who completed the survey (52% response rate; 56% female sex). The majority (61%) supported age restrictions for tackling, and an additional 24% indicated they maybe would support age restrictions. For female respondents, a greater perceived risk of tackle football (odds ratio [OR] 3.83; 95% confidence interval [CI] 1.06-13.83) and greater educational attainment (OR 3.97; 95% CI 1.61-9.80) were associated with greater odds of supporting age restrictions for tackling. For male respondents, having a child 6 to 12 years old was associated with greater odds of maybe supporting age restrictions for tackling (OR 2.34; 95% CI 1.19-4.62).

Conclusions: A majority of US parents across sexes would support age restrictions for tackling in football. This information should inform discussions when guidelines about tackling in youth football are revisited.
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http://dx.doi.org/10.1542/peds.2018-2402DOI Listing
May 2019

The Socioecological Framework: A Multifaceted Approach to Preventing Sport-Related Deaths in High School Sports.

J Athl Train 2019 Apr 14;54(4):356-360. Epub 2019 Mar 14.

Korey Stringer Institute, Department of Kinesiology, University of Connecticut, Storrs.

The socioecological framework is a multilevel conceptualization of health that includes intrapersonal, interpersonal, organizational, environmental, and public policy factors. The socioecological framework emphasizes multiple levels of influence and supports the idea that behaviors both affect and are affected by various contexts. At present, the sports medicine community's understanding and application of the socioecological framework are limited. In this article, we use the socioecological framework to describe potential avenues for interventions to reduce sport-related deaths among adolescent participants.
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http://dx.doi.org/10.4085/1062-6050-173-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522086PMC
April 2019

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).

J Athl Train 2018 Dec;53(12):1143-1155

Injury Prevention Research Center, University of North Carolina at Chapel Hill.

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.
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http://dx.doi.org/10.4085/1062-6050-154-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365066PMC
December 2018

College Football Players Less Likely to Report Concussions and Other Injuries with Increased Injury Accumulation.

J Neurotrauma 2019 07 28;36(13):2065-2072. Epub 2019 Mar 28.

1 Department of Health Care Policy, Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts.

Athletes sometimes choose not to report suspected concussions, risking delays in treatment and health consequences. How and why do athletes make these reporting decisions? Using original survey data from a cohort of college football players, we evaluate two assumptions of the current literature on injury reporting: first, that the probability of reporting a concussion or injury is constant over time; second, that athletes make reasoned deliberative decisions about whether to report their concussion or other injury. We find that athletes are much less likely to report a concussion to a medical professional than they are to report another injury (47% vs. 80%), but no association between reporting and a measure of athletes' ability to switch from fast, reactive thinking to reasoned, deliberative thinking. The likelihood of reporting decreases as the number of injuries and concussions increases, and no athlete reported more than four concussions. Sports medicine clinicians sometimes use four concussions as a time to discuss possibly curtailing sports participation, which may influence athletes' subsequent reporting behavior. Sports medicine clinicians may want to consider athlete injury history as a risk factor for concussion and injury under-reporting.
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http://dx.doi.org/10.1089/neu.2018.6161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602107PMC
July 2019
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