Correction: Currie et al. Reality Check 2: The Cost-Effectiveness of Policy Disallowing Body Checking in Non-Elite 13- to 14-Year-Old Ice Hockey Players. Int. J. Environ. Res. Public Health 2021, 18, 6322.

There was an error in our original publication [...].

Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design.

OBJECTIVES: To understand Canadian university athletic programme concussion management needs, and to describe development and content of a tailored online concussion education tool for Canadian university/college athletes. DESIGN: An integrated knowledge translation multiphased, multimethods approach was used. Phases included a needs assessment survey with university representatives and athletes, content selection, mapping behavioural goals to evidenced-based behaviour change techniques, script/storyboard development, engagement interviews with university athletes and tool development using user-centred design techniques. SETTING: Canadian U SPORTS universities (n=56). PARTICIPANTS: Overall, 64 university representatives (eg, administrators, clinicians) and 27 varsity athletes (52% male, 48% female) completed the needs assessment survey. Five athletes participated in engagement interviews. OUTCOME MEASURES: Surveys assessed previous athlete concussion education, recommendations for concussion topics and tool design, concussion management challenges and interest in implementing a new course. RESULTS: Institutions used a median (Med) of two (range 1-5) approaches when educating athletes about concussion. Common approaches were classroom-style education (50%), online training (41%) and informational handouts (39%). University representatives rated most important topics as: (1) what is a concussion, (2) how to recognise a concussion and (3) how to report a concussion (Medall=4.8/5). Athletes felt symptom recognition (96%) and effects on the brain (85%) were most important. The majority of athletes preferred learning via computer (81%) and preferred to learn alone (48%) versus group learning (7%). The final resource was designed to influence four behaviours: (1) report symptoms, (2) seek care, (3) encourage teammates to report symptoms and (4) support teammates through concussion recovery. Examples of behaviour change techniques included: knowledge/skills, problem-solving scenarios, verbal persuasion and social comparison. Athletes are guided through different interactions (eg, videos, flip cards, scenarios, testimonials) to maximise engagement (material review takes ~30 min). CONCLUSIONS: The Concussion Awareness Training Tool for athletes is the first Canadian education tool designed to address the needs of Canadian university/college athletes.

Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players.

OBJECTIVE: To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion. DESIGN: Prospective cohort study, Safe to Play (2013-2018). SETTING: Youth hockey leagues in Alberta and British Columbia, Canada. PARTICIPANTS: Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions. INDEPENDENT VARIABLES: Psychosocial variables. MAIN OUTCOME MEASURES: Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit. RESULTS: Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery. CONCLUSIONS: Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

Factors Associated With Concussion Rates in Youth Ice Hockey Players: Data From the Largest Longitudinal Cohort Study in Canadian Youth Ice Hockey.

OBJECTIVES: To examine factors associated with rates of game and practice-related concussion in youth ice hockey. DESIGN: Five-year prospective cohort (Safe2Play). SETTING: Community arenas (2013-2018). PARTICIPANTS: Four thousand eighteen male and 405 female ice hockey players (6584 player-seasons) participating in Under-13 (ages 11-12), Under-15 (ages 13-14), and Under-18 (ages 15-17) age groups. ASSESSMENT OF RISK FACTORS: Bodychecking policy, age group, year of play, level of play, previous injury in the previous year, lifetime concussion history, sex, player weight, and playing position. MAIN OUTCOME MEASUREMENTS: All game-related concussions were identified using validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician for diagnosis and management. Multilevel Poisson regression analysis including multiple imputation of missing covariates estimated incidence rate ratios (IRRs). MAIN RESULTS: A total of 554 game and 63 practice-related concussions were sustained over the 5 years. Female players (IRR Female/Male = 1.79; 95% CI: 1.26-2.53), playing in lower levels of play (IRR = 1.40; 95% CI: 1.10-1.77), and those with a previous injury (IRR = 1.46; 95% CI: 1.13, 1.88) or lifetime concussion history (IRR = 1.64; 95% CI: 1.34-2.00) had higher rates of game-related concussion. Policy disallowing bodychecking in games (IRR = 0.54; 95% CI: 0.40-0.72) and being a goaltender (IRR Goaltenders/Forwards = 0.57; 95% CI: 0.38-0.87) were protective against game-related concussion. Female sex was also associated with a higher practice-related concussion rate (IRR Female/Male = 2.63; 95% CI: 1.24-5.59). CONCLUSIONS: In the largest Canadian youth ice hockey longitudinal cohort to date, female players (despite policy disallowing bodychecking), players participating in lower levels of play, and those with an injury or concussion history had higher rates of concussion. Goalies and players in leagues that disallowed bodychecking had lower rates. Policy prohibiting bodychecking remains an effective concussion prevention strategy in youth ice hockey.

Self-reported concussions in Canada: A cross-sectional study.

Background: Traumatic brain injuries (TBIs) are a major public health concern impacting the lives of many Canadians. Among all TBIs, concussions are the most common. However, to date, the incidence of concussions among the Canadian population, has remained unknown. To address this data surveillance gap, this study presents national estimates on the percentage of Canadians aged 12 years or older (excluding those living in the territories) who sustained one or more concussions in 2019. Data and methods: This study used data collected from the Traumatic Brain Injury Rapid Response (TBIRR) module of the 2020 Canadian Community Health Survey, a cross-sectional health survey. Descriptive statistics and logistic regressions were conducted to summarize the information in the TBIRR module. Results: This study found that approximately 1.6% of Canadians aged 12 years or older reported sustaining one or more concussions in 2019. Age was significantly associated with concussion incidence after controlling for sex and annual household income, and the locations and activities surrounding respondents' most serious concussions varied by age group. Over one-third of respondents sustained multiple concussions. Interpretation: The results suggest that certain populations, particularly younger individuals, may be more affected by concussions. While circumstances surrounding concussions vary by age group, the most important contributing factors were sports or physical activities among youth and falls among the adult population. Monitoring concussions among the national population is an important activity in injury surveillance, as it can help evaluate the efficacy of injury prevention intervention and better understand knowledge gaps and the burden of this injury.

Barriers and facilitators to the uptake of the Concussion Awareness Training Tool as continuing medical education in primary care.

Aim: Continuing medical education (CME) informs physicians on current research. The Concussion Awareness Training Tool (CATT) provides education on concussion diagnosis and treatment. The aims of this study were to explore physician CME practices and preferences, understand barriers and facilitators to implementing the CATT as CME, and provide recommendations. Materials & methods: Physicians in British Columbia, Canada participated in an online survey and telephone interview. Descriptive analysis of quantitative data, and text-based data analysis were undertaken to identify themes. Results: Barriers included lack of time and awareness of the resource. Facilitators were its ease of use, accessibility, conciseness and comprehensiveness. Conclusion: The perceptions of barriers and facilitators reported by physicians are important to understand and better promote the use of the CATT.

Doctors take continuing medical education (CME) to stay on top of new information and practices. The Concussion Awareness Training Tool (CATT) is available for doctors to learn more about concussion care. This study looked at how doctors in British Columbia, Canada are taking CME training, and what factors are encouraging or preventing them from using the CATT. Doctors reported a lack of time for taking CME, and not knowing about this resource. Those who had taken the CATT training reported that it is easy to use, accessible, concise, and comprehensive. This information will be used to improve promotion of this resource.

Follow-up visits after a concussion in the pediatric population: An integrative review.

BACKGROUND: Concussions are a significant health issue for children and youth. After a concussion diagnosis, follow-up visits with a health care provider are important for reassessment, continued management, and further education. OBJECTIVE: This review aimed to synthesize and analyse the current state of the literature on follow-up visits of children with a concussive injury and examine the factors associated with follow-up visits. METHODS: An integrative review was conducted based on Whittemore and Knafl's framework. Databases searched included PubMed, MEDLINE, CINAHL, PsycINFO, and Google Scholar. RESULTS: Twenty-four articles were reviewed. We identified follow-up visit rates, timing to a first follow-up visit, and factors associated with follow-up visits as common themes. Follow-up visit rates ranged widely, from 13.2 to 99.5%, but time to the first follow-up visit was only reported in eight studies. Three types of factors were associated with attending a follow-up visit: injury-related factors, individual factors, and health service factors. CONCLUSION: Concussed children and youth have varying rates of follow-up care after an initial concussion diagnosis, with little known about the timing of this visit. Diverse factors are associated with the first follow-up visit. Further research on follow-up visits after a concussion in this population is warranted.

The Concussion Awareness Training Tool for Women's Support Workers Improves Knowledge of Intimate Partner Violence-Caused Brain Injury.

Women who experience physical intimate partner violence (IPV) are at high risk of suffering a brain injury (BI) due to head impacts and/or strangulation. Currently, most staff at women's shelters tend not to be aware of IPV-caused BIs. The objective of this study was to address this by developing a new online module within the Concussion Awareness Training Tool (cattonline.com) specifically focused on IPV-caused BI, and measuring its effectiveness in increasing BI awareness and knowledge among staff members at women's shelters. A mixed-methods approach was used which included (i) a survey to measure participant knowledge before and after completing the module; (ii) a 1-on-1 interview 6 months post-training to better understand participants' perceptions of what effect the training had on how they worked with women in their job; and (iii) an evaluation of the content of the module using behavior change techniques. About 81 participants recruited from staff at women's shelters completed the pre/post survey. The average BI knowledge score increased significantly from the pre-survey (M = 8.12/12, SD = 1.05) to the post-survey (M = 9.72/12, SD = 1.62), t(80) = 9.12, P < .001, d = 1.01). Analysis of the interviews with 9 participants highlighted 3 main themes arising from the module: knowledge, mindfulness, and advocacy. All participants felt their knowledge of IPV-caused BIs had increased and said they would recommend the training to their co-workers. Analysis of the module content revealed the most frequent behavior change techniques were related to instructions on how to perform screening and accommodation for IPV-caused BI. The results showed the module was effective in increasing knowledge of IPV-caused BIs amongst women's shelter staff as well as improving how they advocate for, and are mindful of, their clients with BIs. This online training may help improve the care women with IPV-caused BIs receive, and ultimately improve their quality of life.

Activity and Recovery Among Youth With Concussion: A Meta-analysis.

CONTEXT: Concussions in youth are highly prevalent. Previously, rest was prescribed to prevent adverse outcomes; however, early return to activity is emerging to improve the recovery trajectory. OBJECTIVES: To evaluate the effectiveness of early return to physical and social activity interventions on recovery outcomes in youth with concussion. DATA SOURCES: A systematic review was conducted up to October 2022. STUDY SELECTION: We included randomized controlled trials (RCTs) and non-RCTs that reported effects of activity-based interventions on symptoms, quality-of-life (QoL), and return to preinjury activity levels in children and youth after a concussion. DATA EXTRACTION: Three authors independently extracted data on publication year and country, study setting and design, sample size, participant demographics, intervention, outcome(s), and author conclusion. Meta-analysis was conducted on appropriate RCTs. RESULTS: Twenty-four studies were included in the final review, of which 10 were RCTs. There was a significant effect of activity interventions on symptom reporting (standardized mean difference, 0.39 [95% confidence interval, 0.15 to 0.63]; I2, 0%; P = .002). There was not a significant effect of activity-based interventions on QoL (mean difference, -0.91 [95% confidence interval, -7.76 to 5.94]; I2, 0%; P = .79). No meta-analysis was performed on return to preinjury activity levels because of insufficient number of RCTs conducted. LIMITATIONS: One outcome was excluded from the meta-analysis. Interventions emphasizing social activity were lacking. CONCLUSIONS: Findings indicate that activity-based interventions may significantly improve concussion symptoms. There is insufficient data to understand the effect of activity-based intervention on QoL and return to preinjury activity levels.

Outlining the Invisible: Experiences and Perspectives Regarding Concussion Recovery, Return-to-Work, and Resource Gaps.

Appropriate supports and accommodations are necessary to ensure full concussion recovery and return-to-work (RTW). This research investigated barriers and facilitators to concussion recovery and RTW, and resource gaps reported by adults with concussion ('workers') and workplace and healthcare professionals ('workplaces'). Semi-structured interviews and focus groups were conducted with workers (n = 31) and workplaces (n = 16) across British Columbia. Data were analyzed using inductive content analysis. Facilitators to workers' concussion recovery and RTW included treatment, social support, and workplace and lifestyle modifications. To address barriers, both groups recommended: (a) widespread concussion and RTW education and training (b) standardized concussion recovery guidelines; (c) changing attitudes toward concussion; (d) mental health supports; and (e) increasing awareness that every concussion is unique. Findings can inform best practice for concussion recovery and RTW among professionals in workplaces, healthcare, occupational health and safety, and workers' compensation boards.

No association found between body checking experience and injury or concussion rates in adolescent ice hockey players.

OBJECTIVES: To compare rates of injury and concussion among U-15 (ages 13-14 years) ice hockey players playing in leagues allowing body checking, but who have a varying number of years of body checking experience. METHODS: This 5-year longitudinal cohort included U-15 ice hockey players playing in leagues where policy allowed body checking. Years of body checking experience were classified based on national/local body checking policy. All ice hockey game-related injuries were identified using a validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician. Multiple multilevel Poisson regression analysis was performed, adjusting for important covariates and a random effect at a team level (offset by game exposure hours), to estimate injury and concussion incidence rate ratios (IRRs). RESULTS: In total, 1647 players participated, contributing 1842 player-seasons (195 players participating in two seasons). Relative to no body checking experience, no significant differences were found in the adjusted IRRs for game-related injury for players with 1 year (IRR=1.06; 95% CI: 0.77 to 1.45) or 2+ years (IRR=1.16; 95% CI: 0.74 to 1.84) body checking experience. Similarly, no differences were found in the rates of concussion for players with 1 year (IRR=0.92; 95% CI: 0.59 to 1.42) or 2+ years (IRR=0.69; 95% CI: 0.38 to 1.25) body checking experience. CONCLUSIONS: Among ice hockey players aged 13-14 years participating in leagues permitting body checking, the adjusted rates of all injury and concussion were not significantly different between those that had body checking experience and those that did not. Based on these findings, no association was found between body checking experience and rates of injury or concussion specifically in adolescent ice hockey.

Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents.

OBJECTIVES: The objective of this study is to evaluate the effect of policy change disallowing body checking in adolescent ice hockey leagues (ages 15-17) on reducing rates of injury and concussion. METHODS: This is a prospective cohort study. Players 15-17 years-old were recruited from teams in non-elite divisions of play (lower 40%-70% by division of play depending on year and city of play in leagues where policy permits or prohibit body checking in Alberta and British Columbia, Canada (2015-18). A validated injury surveillance methodology supported baseline, exposure-hours and injury data collection. Any player with a suspected concussion was referred to a study physician. Primary outcomes include game-related injuries, game-related injuries (>7 days time loss), game-related concussions and game-related concussions (>10 days time loss). RESULTS: 44 teams (453 player-seasons) from non-body checking and 52 teams (674 player-seasons) from body checking leagues participated. In body checking leagues there were 213 injuries (69 concussions) and in non-body checking leagues 40 injuries (18 concussions) during games. Based on multiple multilevel mixed-effects Poisson regression analyses, policy prohibiting body checking was associated with a lower rate of injury (incidence rate ratio (IRR): 0.38 (95% CI 0.24 to 0.6)) and concussion (IRR: 0.49; 95% CI 0.26 to 0.89). This translates to an absolute rate reduction of 7.82 injuries/1000 game-hours (95% CI 2.74 to 12.9) and the prevention of 7326 injuries (95% CI 2570 to 12083) in Canada annually. CONCLUSIONS: The rate of injury was 62% lower (concussion 51% lower) in leagues not permitting body checking in non-elite 15-17 years old leagues highlighting the potential public health impact of policy prohibiting body checking in older adolescent ice hockey players.

Socioeconomic factors and substances involved in poisoning-related emergency department visits in British Columbia, Canada. / Facteurs socioéconomiques et substances en cause dans les visites aux urgences liées à des intoxications en Colombie Britannique (Canada).

INTRODUCTION: Canada's opioid crisis has taken thousands of lives, increasing awareness of poisoning-related injuries as an important public health issue. However, in British Columbia (BC), where overdose mortality rates are the highest in Canada, studies have not yet identified which demographic populations most often visit emergency departments (ED) due to all poisonings, nor which substances are most commonly involved. The aim of this study was to explore these gaps, after developing a methodology for calculating ED visit rates in BC. METHODS: Poisoning-related ED visit rates during fiscal years 2012/13 to 2016/17, inclusive, were calculated by sex, age group, poisoning substance and socioeconomic status, using a novel methodology developed in this study. ED data were sourced from the National Ambulatory Care Reporting System and population data from Statistics Canada's 2016 (or 2011) census profiles. RESULTS: During the study period, there were an estimated 81 463 poisoning-related ED visits (351.2 per 100 000 population). Infants, toddlers, youth and those aged 20-64 years had elevated risks of poisoning-related ED visits. Rates were highest among those in neighbourhoods with the greatest material (607.8 per 100 000 population) or social (484.2 per 100 000 population) deprivation. Over time, narcotics and psychodysleptics became increasingly common poisoning agents, while alcohol remained problematic. CONCLUSION: A methodology for estimating ED visit rates in BC was developed and applied to determine poisoning-related ED visit rates among various demographic groups within BC. British Columbians most vulnerable to poisoning have been identified, emphasizing the need for efforts to limit drug overdoses and excessive alcohol intoxication to reduce rates of these preventable injuries.

Evidence of altered interhemispheric communication after pediatric concussion.

OBJECTIVES: To investigate neurophysiological alterations within the typical symptomatic period after concussion (1-month) and throughout recovery (6-months) in adolescents; and (2) to examine relationships between neurophysiological and upper limb kinematic outcomes.METHODS: 18 adolescents with concussion were compared to 17 healthy controls. Transcranial magnetic stimulation (TMS) was used to assess neurophysiological differences between groups including: short- and long-interval intracortical inhibition, intracortical facilitation, short- and long-latency afferent inhibition, afferent facilitation, and transcallosal inhibition (TCI). Behavioral measures of upper limb kinematics were assessed with a robotic device.RESULTS: Mixed model analysis of neurophysiological data identified two key findings. First, participants with concussion demonstrated delayed onset of interhemispheric inhibition, as indexed by TCI, compared to healthy controls. Second, our exploratory analysis indicated that the magnitude of TCI onset delay in adolescents with concussion was related to upper limb kinematics.CONCLUSIONS: Our findings indicate that concussion in adolescence alters interhemispheric communication. We note relationships between neurophysiological and kinematic data, suggesting an affinity for individuals with less concussion-related physiological change to improve their motor behavior over time. These data serve as an important step in future development of assessments (neurobiological and clinical) and interventions for concussion.

Reality Check 2: The Cost-Effectiveness of Policy Disallowing Body Checking in Non-Elite 13- to 14-Year-Old Ice Hockey Players.

Sport-related injuries are the leading cause of injury in youth and are costly to the healthcare system. When body checking is disallowed in non-elite levels of Bantam (ages 13-14 years) ice hockey, the injury rate is reduced, but the impact on costs is unknown. This study compared rates of game injuries and costs among non-elite Bantam ice hockey leagues that disallow body checking to those that did not. Methods: An economic evaluation was conducted alongside a prospective cohort study comparing 608 players from leagues where body checking was allowed in games (Calgary/Edmonton 2014-2015, Edmonton 2015-2016) with 396 players from leagues where it was not allowed in games (Vancouver, Kelowna 2014-2015, Calgary in 2015-2016). The effectiveness measure was rate of game injuries per 1000 player-hours. Costs were estimated based on associated healthcare use within the publicly funded healthcare system as well as privately paid healthcare costs. Probabilistic sensitivity analysis was conducted using bootstrapping. Results: Disallowing body checking reduced the rate of injuries by 4.32 per 1000 player-hours (95% CI -6.92, -1.56) and reduced public and total healthcare system costs by $1556 (95% CI -$2478, -$559) and $1577 (95% CI -$2629, -$500) per 1000 player-hours, respectively. These finding were robust in over 99% of iterations in sensitivity analyses in the public healthcare and the total healthcare system perspectives. There was no statistically significant difference in privately paid healthcare costs (-$65 per 1000 player-hours (95% CI -$220, $99)). Interpretation: Disallowing body checking in non-elite 13-14-year-old ice hockey nationally would prevent injuries and reduce public healthcare costs.

The Impact of COVID-19 on High School Student-Athlete Experiences with Physical Activity, Mental Health, and Social Connection.

COVID-19 restrictions led to reduced levels of physical activity, increased screen usage, and declines in mental health in youth; however, in-depth understandings of the experiences of high school student-athletes have yet to be explored. To describe the experiences of the COVID-19 pandemic on student-athletes' physical activity, social connection, and mental health, 20 high school student-athletes living in Calgary, Alberta participated in semi-structured interviews, designed using phenomenography. Participants reported variations in physical activity, social connections, and mental health which were influenced by stay-at-home restrictions and weather. Access to resources, changes to routines, online classes, and social support all influenced engagement in physical activity. School and sports provided opportunities for in-person social connections, impacted by the onset of the pandemic. Participants reported their mental health was influenced by social connections, online classes, and physical activity. Findings from this study will inform the development of resources for high school student-athletes amidst COVID-19.

Active & Safe Central: using a mixed-methods design and the RE-AIM framework to evaluate a sport and recreational injury prevention resource for practitioners in Canada.

OBJECTIVES: An online, evidence-based resource was created to support the development of sport and recreational injury prevention programmes. The resource, called Active & Safe Central (www.activesafe.ca), provides evidence-based information across the public health approach for a number of sport and recreational activities. The objective of this project was to evaluate the perceived usefulness of Active & Safe Central as an educational tool. DESIGN: A mixed-methods study design, guided by the RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework, was used to evaluate Active & Safe Central. SETTING: Data were collected using an online survey, available to all users of the site, and focus groups (n=2) that took place in Vancouver and Toronto, Canada. PARTICIPANTS: Survey respondents (n=87) were recruited online, including parents, coaches, youth and adult athletes, and teachers. Focus group participants (n=16) were key stakeholders and end users, recruited from academia, local health sectors, sport and recreational organisations, and not-for-profit injury prevention organisations. RESULTS: Post launch, there were 1712 users visiting the website 2306 times (sessions), with the majority representing new users, over returning users (87.5% and 12.5%, respectively). There were 6340 page visits, with the most popular pages including soccer, playgrounds and ice hockey. Active & Safe Central was reported as a credible source of evidence-based sport and recreational information and that the site would be recommended to others. Information collected from focus group participants was used to inform necessary adaptations to the online platform, including critical navigation issues, visualisations and interactivity. The major themes that emerged from focus group and survey data included increased awareness of injury prevention recommendations and that the recommendations would be used in one's own sporting activity and/or practice. CONCLUSIONS: The results of the evaluation suggest the tool is a useful resource for sport and recreational injury information that has significant potential to impact prevention practice.

De-implementing Prolonged Rest Advice for Concussion in Primary Care Settings: A Pilot Stepped Wedge Cluster Randomized Trial.

OBJECTIVE: To evaluate the feasibility and preliminary efficacy of a de-implementation intervention to support return-to-activity guideline use after concussion. SETTING: Community. PARTICIPANTS: Family physicians in community practice (n = 21 at 5 clinics). DESIGN: Pilot stepped wedge cluster randomized trial with qualitative interviews. Training on new guidelines for return to activity after concussion was provided in education outreach visits. MAIN MEASURES: The primary feasibility outcomes were recruitment, retention, and postencounter form completion (physicians prospectively recorded what they did for each new patient with concussion). Efficacy indicators included a knowledge test and guideline compliance based on postencounter form data. Qualitative interviews covered Theoretical Domains Framework elements. RESULTS: Recruitment, retention, and postencounter form completion rates all fell below feasibility benchmarks. Family physicians demonstrated increased knowledge about the return-to-activity guideline (M = 8.8 true-false items correct out of 10 after vs 6.3 before) and improved guideline adherence (86% after vs 25% before) after the training. Qualitative interviews revealed important barriers (eg, beliefs about contraindications) and facilitators (eg, patient handouts) to behavior change. CONCLUSIONS: Education outreach visits might facilitate de-implementation of prolonged rest advice after concussion, but methodological changes will be necessary to improve the feasibility of a larger trial. The qualitative findings highlight opportunities for refining the intervention.

Association between concussion education and concussion knowledge, beliefs and behaviours among youth ice hockey parents and coaches: a cross-sectional study.

OBJECTIVES: To examine the association between self-reported exposure to concussion education and knowledge, beliefs and self-reported behaviour among parents and coaches of youth ice hockey players. DESIGN: Cross-sectional. SETTING: Community ice hockey teams from Calgary and Edmonton, Alberta, Canada. PARTICIPANTS: Parents and coaches of ice hockey players (ages 11-17, all divisions of play). PRIMARY AND SECONDARY OUTCOME MEASURES: Participants completed a questionnaire developed and validated to measure concussion knowledge, beliefs and concussion management behaviour (ie, coaches removing athletes from play; parents taking children with suspected concussions to physicians) consistent with the Health Action Process Approach (HAPA). The questionnaire examined specific HAPA constructs (ie, risk perception, outcome expectancies, action self-efficacy, intention, action planning, maintenance self-efficacy, recovery self-efficacy) relevant to concussion management behaviour. RESULTS: Participants included 786 parents (31.8% with coaching experience) and 10 non-parent coaches. Of the participants, 649 (82.6%) previously received concussion education. Based on a multivariable regression analysis adjusting for coaching experience, previous history of a child sustaining one or more concussions, first aid experience and cluster by team, exposure to concussion education was associated with a mean score difference of 1.36 (95% CI 0.68 to 2.03), p<0.0001, in the knowledge score. Exposure to concussion education was not significantly associated with any of the HAPA constructs based on Wilcoxon rank-sum tests. CONCLUSION: Exposure to concussion education may be associated with small overall differences in concussion knowledge but may not be associated with significant differences in beliefs or intended behaviours related to concussion management among youth hockey parents and coaches.When providing education or recommendations for concussion education sources to coaches and parents, educational strategies grounded in behavioural change theory that specifically target the motivators of behavioural change should be considered.