A Case Report on Heart Rate Variability Biofeedback and Postconcussion Syndrome: Healing the Autonomic Nervous System

Postconcussion syndrome is a devastating condition of the mind, body, and even personality. Mounting research demonstrates that heart rate variability biofeedback can help the concussed individual in three critical ways: (a) eliciting high amplitude oscillations in cardiovascular functions and thereby strengthening self-regulatory control mechanisms;(b) restoring autonomic balance;and (c) increasing the afferent impulse stream from the baroreceptors to restore balance between inhibitory and excitatory processes in the brain.

Differences in Concussion Diagnosis By Sex and Age Group in a General Population

Objectives: Female athletes have a higher risk of concussion than their male counterparts but there is a need to investigate these differences in a general population. We assessed reported concussions during a pre-COVID time period in a claims database to compare the prevalence across sexes and ages. Method(s): Using the MerativeTM MarketScan Commercial and Medicare Databases and Treatment Pathways tool, patients were included in the current study if they had continuous enrollment in the database from January 1, 2018 - December 31, 2019 and were between the ages of 14-65. The prevalence of concussions, identified using ICD-10-DX codes, was calculated for all cohorts (14-17, 18-23, >=24 years) and compared statistically between males and females. A secondary analysis, restricted to those with at least one year of continuous enrollment after the initial concussion, was conducted to determine if the proportion of patients who had a diagnosis code for a concussion at least 30 days after the first concussion differed across cohorts. Result(s): Approximately 9 million patients met the inclusion criteria for the study. A total of 66,098 patients had a claim for a concussion during the study period (56% female). The prevalence of concussions was 0.7% and 0.8% among males and females, respectively (p-value<.0001). Females were more likely to be diagnosed with a concussion than males in all age cohorts, with prevalence decreasing with age. Among patients with at least one concussion, 11.7% of males and 16.9% of females had a diagnosis code for a concussion at least 30 days after the initial code (p-value<.0001). Conclusion(s): This study supports previous research done in athletic populations and provides evidence that in a general population the prevalence of concussions is higher among females across all age groups. Further research is needed to investigate why the risk of concussion differs across sexes.Copyright © 2023

Computerized Cognitive Testing in Long COVID Patients With Prolonged Symptoms of Brain Fog and Cognitive Impairment

Purpose: To identify cognitive impairments in patients (pts) with long COVID using the Cambridge Brain Sciences (CBS) computerized cognitive test (CCT) commonly used to evaluate cognitive function after concussions and traumatic brain injuries. Method(s): Retrospective review from May 2021-Sept 2022 of 16 (4 male, 12 female) patients with long COVID, ages 13- 66 (avg 46), with average of 10 months from COVID infection to time of evaluation. Cognitive (cog) performance and concussion profile symptom scores were assessed with CBS CCT and the Concussion Clinical Profiles screening tool (CP screen) respectively. Result(s): The total CP symptom score average was 34/89 (ranging 7-68) in the cohort. The predominant profile was cog fatigue scoring (1.8/3) on average. CBS CCT tested cog impairment (CI) and was divided into 5 categories (0-4): no CI, borderline (scores between the 21st-30th percentile), mild (1 test < / = 20th percentile), moderate (2-3 tests < / = 20th percentile), and severe CI (>3 tests,/520th percentile). Data showed 2/16 (13%) patients had no CI, 5/16 (31%) had borderline CI, 5/16 (31%) had mild CI, 3/16 (19%) had moderate CI, and 1/16 (6%) pts had severe CI. Although not significant, there was a positive correlation between CI and cog profile score (P = 0.3149) when performing a linear regression test. Deficits were most common in the CBS CTT composites of grammatical reasoning/verbal processing and attention, with 4/16 patients scoring < 20th percentile for each test. The lowest average percentile scores for the cohort were in visuospatial processing and verbal short-term memory. Conclusion(s): Most long COVID patients assessed with CCT demonstrated signs of CI, in particular in verbal processing and memory, followed by visual processing. In addition to the CCT results illustrating CI, the top CP profile of cognitive fatigue in this cohort suggests that the brain fog experienced by long COVID patients may be quantified. Significance: CCT may be a useful tool in assessing and quantifying those with Long COVID with chronic symptoms of cognitive fog, fatigue, or impairment. Targeted interventions aimed at specific deficits can aid in treatment and recovery.

The Impact of Covid-19 Pandemic on Affective Concussion Symptoms in Adolescents

Purpose of Study: Affective symptoms, such as depression, nervousness, anxiety, and irritability, are common yet complicating aspects for concussion patients, therefore addressing exasperations of these symptoms is essential for injury management. This is an especially important consideration for patient populations increasingly susceptible to affective disorders, such as those in rural regions and adolescents. Increases in adolescent mental health problems during the time of the COVID-19 pandemic pose an additional challenge for clinicians managing affective concussion symptoms in rural adolescents. The aim of this study is to quantify the mental health effects of the pandemic by comparing affective concussion symptoms in groups of adolescents with concussion and without concussion in the Central Oregon region. Methods Used: The study is a secondary data analysis of ImPACT Concussion Test symptom scores from a cohort of non-concussed (Baseline) and concussed (Post-Injury) adolescents between the ages of 12-18, pre-pandemic (January 1, 2015 - March 20, 2020) and pandemic (March 21, 2020 - April 1, 2022). Subjects were excluded from the study if they received special education, had a diagnosis of learning disabilities, ADD, dyslexia, autism, or received treatment for headaches, migraines, epilepsy, brain surgery, meningitis, substance use or psychiatric conditions. Prevalence of symptoms of 'headache', 'trouble falling asleep', 'irritability', 'nervousness', 'sadness', and 'feeling more emotional' were noted for each group during each time period. Summary of Results: A total of pre-pandemic non-concussed (n =2667), pre-pandemic concussed (n=643), pandemic non-concussed (n = 593) and pandemic concussed (n=87) were included in the final analysis. There was a statistically significant increase in the proportions of 'nervousness' (p=0.0209) and 'sadness' (p=0.0117) in pre-pandemic and pandemic non-concussed groups. Furthermore, there were statistically significant increases in the proportions of 'headache' (p=0.0331), 'irritability' (p=0.0006), 'nervousness' (p=0.0135), 'sadness' (p=0.0357) and 'feeling more emotional' (p=0.0039) between pre-pandemic and pandemic concussed adolescents. Conclusion(s): This study demonstrates a significant increase in affective symptoms in both concussed and non-concussed groups during the COVID-19 pandemic consistent with other studies. However, those with concussion during the COVID-19 pandemic showed greater number of affective symptoms as well as somatic symptoms (headache) compared to concussed pre-pandemic adolescents. The results of this study support the broader body of research examining the mental health burden of the COVID-19 pandemic on adolescents, and further encourages a biopsychosocial approach to injury management, in which social and emotional components of a patient's life are considered.

Under-researched populations and topics in sport and exercise medicine (SEM)

Correspondence to Dr Sharief Hendricks, Division of Physiological Sciences and Health through Physical Activity, Lifetsyle and Sport Research Centre, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape 7725, South Africa;sharief.hendricks01@gmail.com In this South African Sports Medicine Association (SASMA) edition of BJSM, we spotlight work on under-researched populations and topics in sport and exercise medicine (SEM). Youth sport, TGNC athletes and mental health Access to athlete mental health care, like physical care, can be considered a resource that allows athletes to function, cope with stress, perform and achieve their goals. In 2019, the IOC established the Mental Health Working Group to develop an assessment battery for the early identification of mental health symptoms and disorders in elite athletes.3 The internal consistency of the mental health assessment battery has been tested in elite athletes, but can the same internal consistency be shown for student athletes?

Long-Term Effects of SARS-CoV-2 in the Brain: Clinical Consequences and Molecular Mechanisms.

Numerous investigations have demonstrated significant and long-lasting neurological manifestations of COVID-19. It has been suggested that as many as four out of five patients who sustained COVID-19 will show one or several neurological symptoms that can last months after the infection has run its course. Neurological symptoms are most common in people who are less than 60 years of age, while encephalopathy is more common in those over 60. Biological mechanisms for these neurological symptoms need to be investigated and may include both direct and indirect effects of the virus on the brain and spinal cord. Individuals with Alzheimer's disease (AD) and related dementia, as well as persons with Down syndrome (DS), are especially vulnerable to COVID-19, but the biological reasons for this are not clear. Investigating the neurological consequences of COVID-19 is an urgent emerging medical need, since close to 700 million people worldwide have now had COVID-19 at least once. It is likely that there will be a new burden on healthcare and the economy dealing with the long-term neurological consequences of severe SARS-CoV-2 infections and long COVID, even in younger generations. Interestingly, neurological symptoms after an acute infection are strikingly similar to the symptoms observed after a mild traumatic brain injury (mTBI) or concussion, including dizziness, balance issues, anosmia, and headaches. The possible convergence of biological pathways involved in both will be discussed. The current review is focused on the most commonly described neurological symptoms, as well as the possible molecular mechanisms involved.

Changes in sport-related concussion and traumatic brain injury in New Zealand during the first two years of the COVID-19 pandemic.

OBJECTIVES: To quantify changes in sport-related concussion and traumatic brain injury claims in New Zealand during the first two years of the COVID-19 pandemic (i.e., 2020 and 2021). DESIGN: Population-based cohort study. METHODS: This study included all new sport-related concussion and traumatic brain injury claims that were registered with the Accident Compensation Corporation in New Zealand during 1 January 2010 to 31 December 2021. Annual sport-related concussion and traumatic brain injury claim rates per 100,000 population from 2010 to 2019 were used to fit autoregressive integrated moving average models, from which forecast estimates with 95 % prediction intervals for 2020 and 2021 were derived and compared against corresponding observed values to obtain estimates of absolute and relative forecast errors. RESULTS: Sport-related concussion and traumatic brain injury claim rates were 30 % and 10 % lower than forecasted in 2020 and 2021, respectively, equating to an estimated total of 2410 fewer sport-related concussion and traumatic brain injury claims during the two-year period. CONCLUSIONS: There was a large reduction in sport-related concussion and traumatic brain injury claims in New Zealand during the first two years of the COVID-19 pandemic. These findings highlight the need for future epidemiological studies examining temporal trends of sport-related concussion and traumatic brain injury to account for the impact of the COVID-19 pandemic.

Stakeholder Perspectives on the School Experiences of Students With Traumatic Brain Injury: The Effects of COVID-19 Pandemic on Service Delivery.

BACKGROUND: For students with traumatic brain injury (TBI), the COVID-19 pandemic exacerbated challenges they were already experiencing at school. METHODS: This qualitative study employed focus groups and interviews with students, parents, school, and medical personnel to explore the school experiences of students with TBI. Thematic qualitative analyses were used. RESULTS: Key themes from the analysis include (a) incidence of brain injuries decreased; (b) screen time for students with TBI exacerbated symptoms; (c) COVID protocols at school made it difficult for educators to identify and provide accommodations for students with TBI; (d) COVID protocols at school could inadvertently exacerbate mental health difficulties after a TBI; and (e) COVID-related logistics increased the time between an injury and return to school or return to play. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: The results from this study suggest that professional development for teachers supporting students with TBI is needed, especially for online learning environments. Additionally, because mental/behavioral health concerns may arise for students with TBI in online learning environments, school health care providers can work with families to assess a student's mental health, making referrals to appropriate supports. CONCLUSIONS: There is a significant need for professional development and school-wide infrastructure supportive of students with TBI.

Survey on Sports-Related Concussions among Japanese University Students.

In recent years, head injuries in sports have garnered attention, and in particular, international discussions have been held on the prevention of and response to sports-related concussions (SRCs). The purpose of this study is to investigate past SRCs experienced by university students in Japan, clarify the state and mechanism of such injuries in each sport, and consider the creation of an environment for future SRC prevention and responses. A questionnaire survey on past SRC experience was conducted among 1731 students who belonged to Fukuoka University in Japan and took "sports medicine" classes in 2020. Responses from 1140 students (collection rate: 65.9%) were obtained. According to this survey, it was revealed that 39 students (3.7%) had experienced SRC. The male-female ratio of those who had experienced SRC was 31 males (79.5%) and 8 females (20.5%). Two males had experienced SRC twice. In this study, SRCs were recognized in a variety of sports, not just in a few contact sports. It is necessary to further disseminate education on head injury prevention and SRCs among both athletes and coaches, because SRCs have been frequently recognized in various sports.

Identification of Clinical Measures to Use in a Virtual Concussion Assessment: Protocol for a Mixed Methods Study.

BACKGROUND: Workplace concussions can have a significant impact on workers. The impact of concussion symptoms, combined with challenges associated with clinical environments that are loud, bright, and busy, create barriers to conducting effective in-person assessments. Although the opportunity for remote care in rural communities has long been recognized, the COVID-19 pandemic has catalyzed the transition to virtual assessments and care into the mainstream. With this rapid shift, many clinicians have been completing remote assessments. However, the approaches and measures used in these assessments have not yet been standardized. Furthermore, the psychometric properties of the assessments when completed remotely using videoconference have not yet been documented. OBJECTIVE: Through this mixed methods study, we aim to (1) identify the concussion assessment measures clinicians are currently using in person and are most relevant to the following 5 physical domains: neurological examination (ie, cranial nerve, coordination, motor, and sensory skills), cervical spine, vestibular, oculomotor, and effort assessment; (2) document the psychometric properties of the measures identified; (3) identify measures that appear feasible in a virtual context; and (4) identify practical and technical barriers or challenges, facilitators, and benefits to conducting or engaging in virtual concussion assessments. METHODS: This study will follow a sequential mixed methods design using a survey and Delphi approach, working groups with expert clinicians, and focus groups with experienced clinicians and people living with concussions. Our target sample sizes are 50 clinicians for the Delphi surveys, 4 clinician-participants for the working group, and 5-7 participants for each focus group (roughly 6-10 total groups being planned with at least two groups consisting of people living with concussions). The results from this study will inform the decision regarding the measures that should be included in a virtual assessment tool kit to be tested in a future planned prospective evaluation study. RESULTS: The study is expected to be completed by January 2023. CONCLUSIONS: This mixed methods study will document the clinical measures that are currently used in person and will identify those that are most relevant to assessing the physical domains impacted by concussions. Potential feasibility of using these measures in a virtual context will be explored. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40446.

Trends in concussion mechanism of injury during the COVID-19 pandemic.

OBJECTIVE: The primary objective was to determine the effect of the COVID-19 pandemic on volume, demographics, and mechanisms of injury (MOI) for patients seen at an urban multidisciplinary concussion center. During the first phase of the pandemic in the United States, stay-at-home orders led to decreased group activities and required cancellation of outpatient appointments or initiation of telemedicine visits. METHODS: This study was a retrospective chart review of 3500 patient electronic medical records (EMR). Patients aged 1-99 years were eligible if they had been seen at New York University Langone Health Concussion Center during March 1-December 31, 2019 (control/pre-pandemic period) or during the same period in 2020 (pandemic period). Injury date, appointment date, age, sex, and MOI were captured; statistical analyses were performed using Stata17 (StataCorp, College Station, TX). RESULTS: There were 48% fewer visits during the COVID-19 pandemic period compared to the 2019 control period. There was a decreased proportion of pediatric patients (15% control, 6% pandemic; p = 0.007, chi-square test). Fewer concussions were related to team sports (21% control, 5% pandemic; p < 0.001), and a greater proportion were caused by bicycle accidents (4% control, 8% pandemic; p = 0.037) and assault/domestic violence (3% control, 9% pandemic; p < 0.001). CONCLUSION: The relative proportions of concussion MOI, age distributions, and visit volumes were significantly associated with pre-pandemic vs. pandemic periods, suggesting that COVID-19 changed concussion epidemiology during the pandemic period. This study demonstrates how epidemiologic data may inform future resource allocation during public health emergencies.

Equivalence of In-person and Telehealth Administration of the Physical and Neurological Examination of Subtle Signs Timed Motor Subscale in Youth Recovered from Concussion and Healthy Controls

Background and/or Objectives: The Physical and Neurological Examination of Subtle Signs (PANESS) shows promise as a tool for detecting subtle motor dysfunction after concussion. Our objective was to examine the equivalence of in-person and telehealth administration of the Timed Motor portion of the PANESS in youth recovered from concussion and healthy controls. Design(s): Data was collected as part of a longitudinal cohort-controlled observational study. Setting(s): Clinical research lab and via telehealth. Participant(s): 14 youth (Mean age =14.3, SD=2.41;71.4% female) participating in the last visit of a study examining neural recovery following concussion (7 participants clinically recovered from concussion [Mean years since injury= 1.38, SD= 0.24] and 7 neverconcussed controls). Intervention(s): Not applicable. Main Outcome Measure(s): The PANESS is a brief exam designed to evaluate subtle signs of neuromotor dysfunction in children. The Timed Motor portion requires the participant to complete rapid sequential movements and accounts for speed as well as presence of motor overflow and dysrhythmia scores range from 0-64, higher scores reflect worse performance. In this study, PANESS Timed Motor scores were obtained first via in-person administration and then, within 1 week (Median=0 days), via telehealth administration. Prior research shows high test-retest reliability for in-person administration. Result(s): Paired-sample t-test showed no significant difference between scores obtained in-person (M=15.14 SD= 1.775) and via Zoom (M=15.36;SD=1.848), t (13)= -0.145 p= 0.887. Conclusion(s): The PANESS was developed for inperson administration. During the COVID-19 pandemic, many measures were adapted for telehealth without data suggesting equivalence across administration contexts. Use of telehealth measures has the potential to reduce participant burden and improve access to clinical care. Here, we provide preliminary evidence to suggest equivalence of the PANESS Timed Motor scores obtained in-person and via telehealth in select youth. Future work should explore the psychometric properties of measures adapted for telehealth administration and the emerging utility of the PANESS related to concussion.

147th Annual Meeting American Neurological Association

The proceedings contain 417 papers. The topics discussed include: APOE is independently associated with the heterogeneity of cognitive decline rate in the normal aging-early Alzheimer's disease continuum;bioequivalence and safety comparison of once-weekly donepezil transdermal system with once-daily oral donepezil: results of a phase 1 trial in healthy volunteers;bleed type as a predictor of emotional and behavioral dyscontrol following intracerebral and subarachnoid hemorrhage;case series of manic symptoms following concussion;cognitive impairment in pulmonary hypertension;Creutzfeldt Jacob disease misdiagnosis, a diagnostic challenge and psychological burden: a case series;depressed neurocognitive function with comprehensive neuropsychiatric evaluation among long-haul COVID patients;evaluation of skin adhesion and local skin tolerability of once-weekly donepezil transdermal system: results of a phase 1 trial in healthy volunteers;determining etiologic diagnoses in rapidly progressive dementia: a clinical study;and frequency and distribution of transactive response DNA-binding protein 43 (TDP-43) pathology across the age spectrum in an elderly cohort with and without dementia.

Interdisciplinary Rehabilitation for Concussion Recovery (i-RECOveR): protocol of an investigator-blinded, randomised, case series with multiple baseline design to evaluate the feasibility and preliminary efficacy of a 12-week treatment for persistent post-concussion symptoms.

BACKGROUND: Up to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored. METHODS: Fifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews. DISCUSSION: Results from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes. TRIAL REGISTRATION: ANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118.

Fluid biomarkers and risk of neurodegenerative disease in retired athletes with multiple concussions: results from the International Concussion and Head Injury Research Foundation Brain health in Retired athletes Study of Ageing and Impact-Related Neurodegenerative Disease (ICHIRF-BRAIN study).

Objectives: To investigate the association and utility of blood plasma markers of neurodegeneration in a population of retired athletes self-reporting multiple concussions throughout a sporting career. It is hypothesised that this type of athletic history would cause an increased prevalence of neurodegenerative disease, as detected by biomarkers for neurodegenerative disease processes. Methods: One hundred and fifty-nine participants were recruited (90 males, 69 females, mean age 61.3±9.13 years), including 121 participants who had retired from playing professional or semiprofessional sports and self-reported ≥1 concussion during their careers (range 1-74; mean concussions=10.7). The control group included 38 age-matched and sex-matched controls, with no history of concussion. We measured neurofilament light (NfL) and tau (neurodegeneration markers), glial fibrillar acidic protein (GFAP) (astrocytic activation marker) and 40 and 42 amino acid-long amyloid beta (Aß40 and Aß42) (Alzheimer-associated amyloid pathology markers) concentrations using ultrasensitive single molecule array technology. Results: We found retired athletes reporting one or more concussions throughout an athletic career showed no significant changes in NfL, tau, GFAP and Aß40 and Aß42 concentrations in comparison to a control group. No correlations were found between biomarkers and number of concussions (mean=10.7). A moderate correlation was found between NfL concentration and age. Conclusion: No difference in blood concentrations of neurodegeneration markers NfL, tau, GFAP and Aß40 and Aß42 was found in retired athletes with a history of concussion compared with controls. An increased prevalence of neurodegenerative diseases is not detected by biomarkers in a population self-reporting multiple concussions. Trial registration number: ISRCTN 11312093.

Association of headgear mandate and concussion injury rates in girls' high school lacrosse.

OBJECTIVES: Headgear use is a controversial issue in girls' lacrosse. We compared concussion rates among high school lacrosse players in an American state with a headgear mandate (HM) to states without an HM. METHODS: Participants included high schools with girls' lacrosse programmes in the USA. Certified athletic trainers reported athlete exposure (AE) and injury data via the National Athletic Treatment, Injury and Outcomes Network during the 2019-2021 seasons. The HM cohort was inclusive of high schools from the state of Florida, which mandates the use of ASTM standard F3137 headgear, while the non-HM (NHM) cohort was inclusive of high schools in 31 states without a state-wide HM. Incidence rate ratios (IRRs) and 95% CIs were calculated. RESULTS: 141 concussions (HM: 25; NHM: 116) and 357 225 AEs were reported (HM: 91 074 AEs; NHM: 266 151 AEs) across all games and practices for 289 total school seasons (HM: 96; NHM: 193). Overall, the concussion injury rate per 1000 AEs was higher in the NHM cohort (0.44) than the HM cohort (0.27) (IRR=1.59, 95% CI: 1.03 to 2.45). The IRR was higher for the NHM cohort during games (1.74, 95% CI: 1.00 to 3.02) but not for practices (1.42, 95% CI: 0.71 to 2.83). CONCLUSIONS: These findings suggest a statewide HM for high school girls' lacrosse is associated with a lower concussion rate than playing in a state without an HM. Statewide mandates requiring ASTM standard F3137 headgear should be considered to reduce the risk of concussion.

No Diving! National Estimates and Characteristics of Diving-related Injuries in Children and Adolescents from 2008-2020

Background: Recreational swimming/diving is the most common physical activity among US children and a significant cause of preventable morbidity across the United States. There are an estimated 50 million Americans that participate in swimming per year, 16 million of whom are children. Despite the popularity of swimming and diving, there are few up-to-date national divingrelated injury analyses, and no comprehensive injury analysis has been performed since the institution of International Swimming Pool •Spa Code (ISPSC) in 2012, which regulate diving equipment and design. This study offers a much-needed update on the national epidemiology of diving-related orthopedic injuries. Methods: The Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) database was queried for patients aged 0-18 from 2008- 2020 who presented to any of the approximately 100 NEISSparticipating emergency departments (EDs) for a diving-related injury. The patient cohort was identified using a search for consumer product code-1278 (diving). Injuries involving diving accessories, running, hitting, or tripping over the diving board, and injuries resulting from contact between two or more divers, were excluded. Infections were excluded. Dive characteristics such as dive height, dive skill, dive direction, and dive sequence were determined from case narratives. Descriptive statistical analysis was performed using Stata 16. Results: From 2008-2020 there were 1,157 cases of diving-related injury corresponding to a national estimate of 35,648 injuries (CI=28,067 - 43,230;Table 1). Children aged 10-14 accounted for 42% of all injuries, while adolescents aged 15-19 accounted for 38%. Nearly twice as many injuries occurred in boys compared to girls (64.2% vs 35.8% of total injuries, respectively). From 2008-2012, there were an average estimated 3,191 injuries per year. From 2013-2019, the yearly average decreased to 2,633 injuries (Figure 1). Due to the COVID-19 pandemic, there were relatively few (1,261) injuries in 2020. Compared to 2012, there were an estimated 1,081 fewer diving injuries in 2013, the first year the ISPSC codes were widely adopted. Lacerations were the most reported diagnosis for all years (24.9% of injuries). The head and neck were the mostinjured body parts (46.4% of injuries), followed by the face (17.4% of injuries), and lower extremities (16.6% of injuries). Concussions and nerve injury accounted for 6.7% and 0.1% of injuries, respectively. When the mechanism of injury was reported, unintentional contact with the diving board or platform was the most common cause (27.2% of injuries). Conclusion: Diving injuries are common in children and adolescents, especially in boys aged 10-19. Since the 2012 adoption of international safety standards for swimming pool design and operation, the average number of yearly divingrelated injuries has fallen by nearly 600 injuries/year. There was a significant reduction in diving-related injury corresponding with the COVID-19 pandemic.

The Effect of Protective Headgear on Concussion Injury Ratesin High School Girls' Lacrosse

Background: The use of headgear is a controversial issue in girls' lacrosse with competing arguments pitting the potential benefits of protective headgear versus the potential for increased aggression and related injury due to risk compensation. However, there is scant field-based evidence regarding the effectiveness of protective headgear for reducing the risk of concussion among girls' lacrosse players to support either argument. Furthermore, there is a recognized difference in lacrosse game play geographically with some regions having mature and others still developing girls' lacrosse traditions. Therefore, we aimed to (i) compare concussion rates among high school lacrosse players with headgear versus without headgear;and (ii) compare concussion rates among players with headgear versus without headgear among states with “emerging” lacrosse play. Methods: Study participants included high school girls' lacrosse players from across the country during the Spring 2019 season, the initial part of the 2020 season (prior to the COVID-19 shutdown), and through the middle of the 2021 season. A convenience sample of high schools with athletic trainers were recruited to report injury and athlete exposure (AE) data for girls' lacrosse to the High School National Athletic Treatment, Injury and Outcomes Network (NATION) injury surveillance system. Comparisons were made between concussion rates in the state of Florida (a state with emerging game play that mandates the use of headgear during high school girls' lacrosse participation) to (i) all states without a headgear use mandate, and (ii) emerging states without a headgear use mandate. Emerging states were categorized a-priori by an expert panel as states other than CT, DC, DE, MA, MD, ME, NC, NH, NJ, NY, PA, RI, VA, and VT. Incidence Rate Ratios (IRR) and 95% Confidence Intervals (CI) were calculated. IRRs with corresponding CIs that excluded 1.000 were deemed statistically significant. Results: A total of 84 concussions (Headgear: 20;Non-Headgear: 64) and 239,693AE were reported (Headgear: 78,464AE;Non-Headgear: 161,229AE) across all games and practices. Concussion incident rates per 1000 AE were (Headgear: 0.255;and Non-Headgear: 0.397;IRR = 1.557, 95% CI: 0.943 - 2.573). Comparing incident rates for Headgear to the Emerging Non-Headgear states (61,197 AE;0.458 concussions per 1000 AE) yielded an IRR of1.795 (95% CI: 1.011, 3.186). Conclusion: These interim findings indicate that concussion rates among high school girls' lacrosse players not wearing headgear were 56% higher than those wearing headgear in the state of Florida, although these results did not reach statistical significance. In comparison with other emerging states where the level of lacrosse play is similar, players not wearing headgear experienced a 79.5% higher rate of concussion (statistically significant). Final results will include data from the remainder of the 2021 season.

Canadian Neurological Sciences Federation 2022 Congress, CNSF

The proceedings contain 174 papers. The topics discussed include: deep learning prediction of response to disease modifying therapy in primary progressive multiple sclerosis;changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: a population study;a novel recessive TNNT1 congenital core-rod myopathy in French Canadians;identification of predictors of response to Erenumab in episodic and chronic migraine in a cohort of patients: a preliminary analysis;entropy on routine EEG: an interictal marker of seizure frequency?;can quantitative susceptibility mapping help diagnose and predict recovery of concussion in children?;neuropathology of eight cases of the new Brunswick cluster of neurological syndrome of unknown cause (NSUC);does gender equality exist in the surgical management of degenerative lumbar disease?;cerebral venous sinus thrombosis in preterm infants;endovascular treatment of acute ischemic stroke in patients with pre-morbid disability: a meta-analysis;and muscular MRI pattern recognition for muscular dystrophies: the era of artificial intelligence beyond a systematic review.