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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.

Aim/objectiveThe objective of this study was to provide a meta-analysis examining the effects of football heading.DesignMeta-analytical review on football heading effects on neurocognitive performance, cognition and symptom reports.Data sourcesCombinations of the key terms were entered into the following electronic database search engines: Cochrane Libraries, PyscARTICLE, PyscINFO, PubMed, ProQuest, SPORTDiscus and Web of Science on 7 July 2016.Eligibility criteria for selecting studiesThe following inclusion criteria were used to determine eligibility for studies: (1) the study examined and reported on soccer athletes; (2) the population's age, sex and sport position was described; (3) cognitive function, symptoms, balance or other outcomes were quantitatively measured; (4) football heading exposure was quantitatively measured between at least two groups and (5) the study was written in the English language after December 1979.ResultsThe literature search process identified 467 unique studies. After applying exclusion criteria, 28 studies remained. Included studies had a total of 2288 participants (female participants =933, male participants =1355), aged 13–70 years. The overall results of random effects modelling of football heading were found to be inconclusive across all outcomes, groups and time points. No moderating variables related to methodological, sample or study characteristics were supported in the analysis; age was a potential moderating variable.Summary/conclusionsWe provide the first meta-analytical review of football heading effects aggregated from multiple studies and extended findings from a recent systematic review of the effects of football heading. Our analysis indicates no overall effect for heading a football on adverse outcomes.

Background Up to 1.9 million youth in the USA sustain a concussion each year, and up to 30% experience persistent post-concussive symptoms (PPCS) lasting 1 month or more. PPCS can substantially interfere with social, emotional, and academic functioning. Despite these concerns, few evidence-based treatments are available for youth with PPCS. We previously found effectiveness in treating youth with concussion using a collaborative care intervention that integrates mental health care into a medical model, with improvements in concussive symptoms and quality of life at 1 year. Using the multiphase optimization strategy (MOST) framework, we now aim to assess the contribution of each of the three components that were part of collaborative care: concussion-focused cognitive behavioral therapy (cf-CBT), parenting skills training (PST), and care management (CM). Methods The MOST factorial design examines all three intervention components with two levels of each (present or absent), resulting in 8 possible treatment combinations. We will recruit 368 youth with PPCS from 2 geographic locations (Seattle and Dallas), randomizing them to 1 of 8 treatment groups. Youth and/or parents will attend treatment sessions via video conferencing software over 3 months, and complete surveys regarding primary outcomes (concussive symptoms and health-related quality of life) and secondary outcomes (sleep, pain, mood, and parental distress) at 6 weeks and 3, 6, and 12 months. We will also assess potential mediators and moderators to allow for future tailoring and refinement. Discussion The overarching goal of this investigation is to determine which collaborative care components (delivered individually or in combination) are most effective in treating PPCS in concussion-exposed youth. The investigation will inform mental health screening, intervention, and referral procedures for youth and families following concussion. At the completion of this study, we will have an optimized and refined intervention for youth with PPCS ready for large-scale implementation and dissemination. Trial registration ClinicalTrials.gov NCT06036147. Registered on September 13, 2023.

Background. Parental communication about the importance of reporting concussion symptoms can influence a child’s attitudes about such reporting, and is likely related to perceived threat of concussion. However, parental investment in child sport achievement might impede this communication. Purpose. To examine the relationship between perceived threat of concussion and parent–child communication regarding concussion symptom reporting, and the potential interaction with parental pressure regarding child sport achievement. Method. A total of 236 parents of youth soccer players completed an anonymous online survey. Results. There were greater odds of encouraging concussion reporting among parents who perceived that their child had a greater likelihood of sustaining a concussion (OR = 1.03, 95% CI [1.01, 1.04]) and lower odds among parents who exhibited greater parental sport pressure (OR = 0.88, 95% CI [0.78, 0.99]). Parents whose child had a prior concussion were much more likely to communicate with their child about concussion reporting (OR = 7.86, 95% CI [3.00, 20.55]). Conclusion. Initiatives are needed to support healthy sport parenting, particularly focusing on parental encouragement of concussion reporting. Possible directions for concussion education for parents based on the results of this study include providing parents with concrete guidance about the important role they can play in encouraging their child to report symptoms of a concussion, communicating the athletic consequences of continued sport involvement while experiencing symptoms of a concussion, and using narrative messaging with exemplars to personalize the information for parents of youth who have not previously sustained a concussion.

C. elegans will orient and travel in a straight uninterrupted path directly towards the negative pole of a DC electric field. We have sought to understand the strategy worms use to navigate to the negative pole in a uniform electric field that is fixed in both direction and magnitude. We examined this behavior by quantifying three aspects of electrotaxis behavior in response to different applied field strengths: the mean approach trajectory angles of the animals' tracks, turning behavior (pirouettes) and average population speeds. We determined that C. elegans align directly to the negative pole of an electric field at sub-preferred field strength and alter approach trajectories at higher field strengths to maintain taxis within a preferred range we have calculated to be ~ 5V/cm. We sought to identify the sensory neurons responsible for the animals' tracking to a preferred field strength. eat-4 mutant animals defective in glutamatergic signaling of the amphid sensory neurons are severely electrotaxis defective and ceh-36 mutant animals, which are defective in the terminal differentiation of two types of sensory neurons, AWC and ASE, are partially defective in electrotaxis. To further elucidate the role of the AWC neurons, we examined the role of each of the pair of AWC neurons (AWCOFF and AWCON), which are functionally asymmetric and express different genes. nsy-5/inx-19 mutant animals, which express both neurons as AWCOFF, are severely impaired in electrotaxis behavior while nsy-1 mutants, which express both neurons as AWCON, are able to differentiate field strengths required for navigation to a specific field strength within an electric field. We also tested a strain with targeted genetic ablation of AWC neurons and found that these animals showed only slight disruption of directionality and turning behavior. These results suggest a role for AWC neurons in which complete loss of function is less disruptive than loss of functional asymmetry in electrotaxis behavior within a uniform fixed field.

Background Subthreshold exercise, defined as aerobic exercise below the level that causes symptoms, has been utilized as a treatment for youth with persistent postconcussive symptoms (PPCS), but there is currently little evidence to guide use. In addition, prior studies of exercise for PPCS have all required multiple in-person visits. We developed a virtual approach for delivering subthreshold exercise to youth with PPCS called the Mobile Subthreshold Exercise Program (MSTEP), and we have now been funded to conduct a large national randomized controlled trial (RCT) to test its efficacy for reducing concussive symptoms and improving health-related quality of life. Methods This investigation is an RCT comparing MSTEP to an active control. We will recruit 200 adolescents 11–18 years old with postconcussive symptoms persisting for at least 1 week but less than 1 year. Youth will be randomized to receive either 6 weeks of subthreshold exercise (MSTEP) or a stretching condition (control). Youth and parents will complete surveys of concussive symptoms at baseline, weekly during the intervention, and at 3 and 6 months. The primary outcomes will be trajectory of concussive symptoms and health-related quality of life over the 6 months of the study. Secondary outcomes will include depression, anxiety, and sleep quality. We will also assess potential mediators of treatment effects including moderate-vigorous physical activity and fear avoidance of concussive symptoms. Discussion This multisite RCT of MSTEP will provide vital information regarding the efficacy of a virtually delivered subthreshold exercise program for youth with PPCS, and insight regarding potential mediators of treatment effects, including objectively measured physical activity and fear avoidance of concussive symptoms. Trial registration ClinicalTrials.gov NCT04688255. Registered on December 29, 2020.

BackgroundMost concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes. MethodsA mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9–16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155).ResultsInternal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to “always” tell their coach about symptoms of a suspected concussion.ConclusionsThe CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.

To assess whether the King-Devick (KD) test is useful as a prognostic test for prolonged concussion symptoms by examining the relationship between a) change in performance on KD test from baseline to within two days post-injury and b) the absolute KD time at post-concussion testing, with an outcome of time to return to play (RTP). Prospective Cohort Study. Collegiate varsity athletes in the Concussion Assessment, Research, and Education (CARE) Consortium completed baseline and post-injury King-Devick tests from 2014 to 2018. Two exposures were evaluated: 1) change in KD score from baseline to within two days post-injury and 2) absolute KD score within two days post-injury, adjusted for baseline KD. We used Cox proportional hazards models to analyze the relationships between these exposures and time to RTP post-concussion. A total of 309 concussion injuries were included. Median baseline KD score was 40.0 s (IQR: 35.8, 45.2). Median post-injury KD score was 45.8 s (IQR: 39.8, 57.1). Median number of days until RTP in this cohort was 11 (IQR: 8, 17). Post-injury KD score adjusted for baseline KD had a stronger association with time to RTP duration (HR: 0.99 (0.98, 1.00), p = 0.03) than the difference in KD score from baseline to post-injury (HR: 0.99 (0.99, 1.00), p = 0.07). Higher post-injury KD scores are associated with longer RTP. The association between KD post-concussion test and longer RTP warrants further investigation to assess the utility of the KD for prognostication in a clinical setting.

BackgroundThe American Academy of Pediatrics has recommended that opportunities for non-tackling American football (e.g., flag football) be expanded, given concerns about the risks of brain trauma from tackle football. This study tested the hypothesis that flag football would be more accessible in communities characterised by higher socioeconomic status residents.MethodsIn July 2017, the locations of community-based organisations offering youth flag and tackle football for youth between the ages of 6 and 13 in two US states (Georgia and Washington) were aggregated (n=440). Organisations were coded in terms of the availability of tackle and/or flag football teams for youth at each year of age between 6 and 13. Multivariate logistic regression analyses were used to assess the odds of a community-based football organisation offering flag football, by community socioeconomic and demographic characteristics.ResultsIn both states, communities with more educated residents were more likely to offer flag football for youth aged 6–12. For example, among 6 year-olds every 10% increase in the number of adult residents with a college education was associated with 1.51 times the odds of flag football availability (95% CI 1.22 to 1.86, P<0.001).ConclusionThese results suggest that youth living in communities characterised by low educational attainment are less likely than other youth to have the option of a lower contact alternative to tackle football. Relying on voluntary community-level adoption of lower contact alternatives to tackle football may result in inequitable access to such sport options. This may contribute to an inequitable burden of brain trauma from youth sport.

Physical contact such as tackling is a part of youth sport, but associated with concussion risk. Coach communication with athletes about how to approach contact could be a strategy to reduce concussion risk. We interviewed n = 50 adult stakeholders (coaches, referees and administrators) in youth football and soccer to identify barriers and facilitators to coach communication about contact. We framed interviews using the Theory of Planned Behavior, discussing: knowledge/experience, attitudes/beliefs, norms/values and perceived behavioral control. Stakeholders could easily describe ‘good’ contact (knowledge/experience) like keeping your head up (football) and tackling shoulder-to-shoulder (soccer), and ‘bad’ contact like spearing (football) and retaliating against an opponent (soccer). They also talked about the importance of sportsmanship and playing by the rules. Most coaches believed ‘bad’ contact was associated with greater injury (attitudes/beliefs). Coaches felt responsible for managing contact (norms/values), but also described not receiving any information indicating that this was part of their role. Coaches worried about creating a fear of injury, and felt it was important for discussions to be framed positively (perceived behavioral control). In summary, youth football and soccer coaches believe ‘bad’ contact is associated with greater injury risk and feel it is their role to provide youth guidance about contact, but describe a lack of institutional guidance regarding this role. They also are concerned about barriers, including creating fear, and describe ways to address this barrier with language. Developing programs to support coach communication about contact with youth athletes presents a potential strategy for concussion prevention.