Headgear mandates in high school girls' lacrosse: investigating differences in impact rates and game play behaviors.

BACKGROUND/OBJECTIVE: Headgear designed to protect girls' lacrosse athletes is widely available and permitted for voluntary use; however, it remains unknown how policies mandating headgear use may change the sport and, particularly regarding impacts during game-play. Therefore, this study compares the impact rates and game play characteristics of girls' high school lacrosse in Florida which mandates headgear use (HM), with states having no headgear mandate (NHM). MATERIALS AND METHODS: Video from 189 randomly-selected games (HM: 64, NHM: 125) were analyzed. Descriptive statistics, Impact Rates (IR), Impact Rate Ratios (IRR), Impact Proportion Ratios (IPR), and 95% Confidence Intervals (CI) were calculated. IRRs and IPRs with corresponding CIs that excluded 1.00 were deemed statistically significant. RESULTS: 16,340 impacts (HM:5,821 NHM: 10,519; 86.6 impacts/game, CI: 88.6-93.3) were identified using the Lacrosse Incident Analysis Instrument (LIAI). Most impacts directly struck the body (n = 16,010, 98%). A minority of impacts directly struck a player's head (n = 330, 2%). The rate of head impacts was significantly higher in the HM cohort than NHM cohort (IRR = 2.1; 95% CI = 1.7-2.6). Most head impacts (n = 271, 82%) were caused by stick contact in both groups. There was no difference in the proportion of penalties administered for head impacts caused by stick contact between the HM and NHM cohorts (IPR IRRHM/NHM = 0.98; CI = 0.79-1.16). However, there was a significantly greater proportion of head impacts caused by player contact that resulted in a penalty administered in the HM cohort (IPR = 1.44 CI = 1.17-1.54). CONCLUSION: These findings demonstrate that mandating headgear use was associated with a two-fold greater likelihood of sustaining a head impact during game play compared to NHM states. A majority of head impacts in both HM and NHM states were caused by illegal stick contact that did not result in penalty.

High school girls' lacrosse athletes participating in a state with a headgear mandate was twice as likely to sustain a head impact than those participating in states without headgear mandates.Stick contact remains the most common mechanism of head impacts in girls' lacrosse, regardless of mandating headgear.Regardless of whether headgear was or was not mandated, most head impacts caused by stick contact did not result in a penalty.

More Than Skin Deep: Patient-Provider Racial and Ethnic Concordance and Discordance in Collegiate Athletics and Concussion Management.

CONTEXT: There is strong evidence that racial and ethnic disparities exist in multiple arenas of health and wellness. The causes of racial and ethnic differences in healthcare are multi- dimensional, one factor that may impact injury/illness communication, interactions, and outcomes is patient-provider racial and ethnic concordance. At present, it is unclear what role patient-provider racial and ethnic concordance and discordance plays in facilitating concussion care for collegiate athletes. OBJECTIVE: Investigate the presence of athlete-athletic trainer (AT) racial and ethnic concordance and discordance amongst diagnosed concussion cases, and examine if racial and ethnic concordance and discordance influences time (in days) until diagnosis, symptom resolution, or return-to-sport clinical milestones in collegiate athletes. DESIGN: Retrospective cohort study. SETTING: Collegiate athletics. PATIENTS OR OTHER PARTICIPANTS: A total of 694 concussion cases [38.6% (n=268) sustained by women, 61.4% (n=426) sustained by men] that occurred within the 2015-2016 through 2019- 2020 sport seasons at 9 institutions. MAIN OUTCOME MEASURE(S): The number of days from date of injury to diagnosis, symptom resolution, and return-to-sport; and from date of diagnosis to symptom resolution and return-to- sport. RESULTS: Overall, 68.4% (n=475) of concussion cases had patient-provider racial and ethnic concordance and 31.6% (n =219) were discordant. All concordant pairs included a White athlete and White AT. Time to diagnosis differed between the concordant and discordant groups (median[IQR]=1[0,2] versus 0[0,1], respectively) only in the model adjusted for sex, sport-type, and availability of an AT (OR[CI95]=1.46[1.07, 1.85]). There were no other group differences. CONCLUSIONS: One-third of concussion cases had athlete-AT racial and ethnic discordance. While this group was diagnosed with a concussion 1-day sooner than the concordant group, no differences were observed for any concussion recovery milestones. These findings suggest that patient-provider racial and ethnic concordance may play a minor role in concussion recognition or reporting, but not necessarily in the management and recovery thereafter.

Academic adjustments and concussion recoveries in NCAA student-athletes: a LIMBIC MATARS investigation.

OBJECTIVE: The aim of this study was to investigate the association between academic adjustments and recovery from sport-related concussions (SRCs) in collegiate athletes. MATERIALS AND METHODS: A retrospective medical chart review was performed between the 2015-2016 and 2019-2020 sport seasons at 11 Long-term Impact of Military-relevant Brain Injury Consortium Military and Tactical Athlete Research Study (LIMBIC MATARS) sites. Days between injury and symptom resolution, and injury and return to sport (dependent variables) for collegiate athletes who did or did not receive academic adjustments (independent variable) were analyzed using Mann-Whitney U tests. RESULTS: The number of days between date of injury and symptom-resolution between those who did (median = 9 [interquartile range = 5,16]) and did not have (7[3,12]) academic adjustments were statistically different (z=-2.76, p < 0.01, r=-0.17). However, no differences were observed between days to return to sport among those who did (14[10,22]) and did not (13[8,20]) receive assigned academic adjustments (z= -1.66, p = 0.10, r= -.10). CONCLUSIONS: Recovery trajectories were similar between athletes diagnosed with a SRC who did or did not receive academic adjustments.. Our findings suggest academic adjustments supported recovery for those who needed academic adjustments. Clinicians and healthcare professionals should assist and support collegiate athletes after SRCs on an individual basis, including academic adjustments when appropriate based on patient presentation.

Exploring the relationship between contraceptive medication use and concussion recovery in female collegiate athletes: a LIMBIC MATARS consortium investigation.

OBJECTIVE: While recovery from concussion is variable, women are more likely to report symptoms, experience worse outcomes, and have longer recovery trajectories following concussion than men. Preliminary data suggest that hormonal fluctuations, specifically progesterone, may be associated with this variability. This study aimed to understand the effect of contraceptive medication on concussion recovery. METHODS: A retrospective chart review using consensus-based common data elements was conducted at 11 NCAA institutions as part of the LIMBIC MATARS consortium. Participants included female collegiate athletes diagnosed with a concussion who did (n = 117) or did not report (n = 339) contraceptive medication use. Number of days between diagnosis and symptom resolution were compared using Mann-Whitney U tests. Self-reported diagnosis of attention deficit hyperactivity disorder, concussion history, anxiety, and depression was compared using Chi-squared tests. RESULTS: The proportions of participants who did or did not take contraceptive medication were similar across covariates. Female athletes regardless of contraceptive medication use recovered similarly following a concussion. CONCLUSIONS: Our findings suggest that contraceptive medication use did not significantly impact concussion recovery. Future prospective investigations should examine documentation practices and operationalize terminology for hormonal contraceptive medication to better understand their role on recovery from sport-related concussion in female collegiate athletes.

Access to athletic trainers and sex as modifiers of time to reach clinical milestones after sport-related concussion in collegiate athletes.

OBJECTIVE: Investigate whether an athlete's biological sex and exposure to a dedicated athletic trainer (AT) were related to clinical milestones after a sports-related concussion (SRC). DESIGN: Retrospective chart review. METHODS: Medical charts of collegiate athletes (n = 196 [70.9% female]) diagnosed with SRC were reviewed to extract: biological sex, dedicated AT exposure for their sport (yes/no), and time (days) to reaching clinical milestones (diagnosis, symptom resolution, unrestricted return to sport [RTS]). Mann-Whitney U tests were used to determine whether time to clinical milestones differed by sex, AT exposure, or their interaction. Proportions of same-day diagnoses and times to diagnosis, symptom resolution, and unrestricted RTS were evaluated with chi-squared and spearman's rank correlations, respectively. RESULTS: There were no significant differences in times to reaching any clinical milestone by sex, AT exposure, or their interaction (ps > 0.05). Forty-three percent of participants were diagnosed on the day of their SRC. This did not differ by sex or AT exposure (ps > 0.29). Longer times to SRC diagnosis were associated with more days to symptom resolution (ρ = 0.236, p = 0.001) and unrestricted RTS (ρ = 0.223, p < 0.001). CONCLUSIONS: Athlete sex and AT exposure were not associated with times to reach any clinical milestone; however, delayed diagnosis was associated with longer times to reach clinical recovery.

Lost in translation: the association of international status and native language on concussion in collegiate athletes in the United States.

OBJECTIVE: The purpose of this study was to characterize the associations of international student status and native language on time (in days) with the date of injury to (i) diagnosis, (ii) symptom resolution, and (iii) return to sport. METHODS: Utilizing data from a cross-sectional cohort of 1,044 concussion cases from LIMBIC MATARS member institutions (n = 11) in the US, we conducted two, matched case-control designs. Cases were divided into two groups: (i) international (n = 32) or domestic students (n = 32) and (ii) English as an Additional Language (EAL) speakers (n = 18) or Native English language speakers (n = 18). Both groups were individually matched to their respective controls based on gender, age, sport, and preexisting health conditions. RESULTS: There were no significant differences in days from injury to diagnosis (p = 0.94), symptom resolution (p = 0.64), or return to sport (p = 0.15) between international and domestic athletes. EAL speakers experienced symptom resolution approximately 7.5 days sooner (Md = 4.50; IQR = 4.00, 8.00) than Native English language speakers (Md = 12.00; IQR = 7.00, 21.00, p = 0.01). CONCLUSIONS: Our findings suggest that native language is associated with symptom resolution in collegiate athletes. Healthcare professionals should consider barriers related to native language that may impact symptom reporting and the overall injury experience of diverse collegiate athletes.

Concussion diagnosis and recovery in relation to collegiate athletic department classification: a LIMBIC MATARS consortium investigation.

PURPOSE: We investigated time to reach concussion diagnosis and recovery milestones in collegiate athletes relative to their schools' National Collegiate Athletic Association (NCAA) classification. METHODS: We retrospectively examined 849 (43.1% female) concussion cases from 11 NCAA institutions (Division I Power 5 [n = 4], Division I Non-Power 5 [n = 4], and Division II/III [n = 3]) from the 2015-16 to 2019-20 athletic seasons. Our primary outcome measures were days to reach specific clinical milestones following concussion. RESULTS: Median (IQR) time from injury to diagnosis was significantly longer at Division II/III institutions (1 [0-4] days) compared to Division I Power 5 (0 [0-1] days) and Division I Non-Power 5 (0 [0-1] days) institutions (p < 0.001). Likewise, Division II/III athletes (15 [11-22] days) took significantly longer to return to sport after concussion than Division I Power 5 (10 [7-16] days) and Division I Non-Power 5 (11 [7-18.5] days) athletes (p < 0.001). CONCLUSION: Division II/III athletes had delayed concussion diagnoses and return to sport timelines compared to Division I athletes. Our results suggest that differences in sports medicine resources across NCAA divisions may influence injury recognition and recovery in collegiate athletes with concussion.

Physical activity and recovery following concussion in collegiate athletes: a LIMBIC MATARS Consortium Investigation.

OBJECTIVE: To investigate whether routine daily activities (RDA), non-prescribed exercise (Non-ERx), or prescribed exercise (ERx) were associated with recovery from sport-related concussion (SRC) in collegiate athletes. MATERIALS AND METHODS: Data for this cross-sectional, retrospective chart review of collegiate athletes diagnosed with SRC (n = 285[39.6% female], age = 19.5 ± 1.4 years) were collected during the 2015-16 to 2019-20 athletic seasons. The independent variable was group (RDA, Non-ERx, ERx). Dependent variables included days from date of diagnosis to symptom resolution (Dx-SR) and SR to return to sport (SR-RTS). RESULTS: Those in the Non-ERx group took nearly 1.3 times longer to achieve SR (IRR = 1.28, 95% CI: 1.11, 1.46) and, 1.8 times longer for RTS (IRR = 1.82, 95% CI: 1.11, 2.71) when compared to those in the RDA group. No other comparisons were significant. CONCLUSION: Collegiate athletes in the Non-ERx group took approximately 1 week longer to achieve SR as compared to the RDA and ERx groups. Our findings suggest that if exercise is recommended following SRC, it must be clearly and specifically prescribed. If exercise parameters cannot be prescribed, or monitored, RDA appear to be similarly beneficial during recovery for collegiate athletes with concussion.

Language Matters: Comparisons of Concussion Assessments Among English and Spanish Speaking Middle School Athletes.

CONTEXT: The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) is among the most widely used international pediatric concussion evaluation tools. The tool's English-only development may limit its use for patients who speak different languages. Prior research suggests preferred language (i.e., home language) could be associated with concussion assessments in adults, however this is not well understood among pediatric athletes. OBJECTIVE: To compare baseline Child SCAT5 assessment outcomes between middle school athletes whose home language is Spanish and matched controls whose home language is English. DESIGN: Case-Control. SETTING: Middle School Athletics. PATIENTS OR OTHER PARTICIPANTS: Athletes self-reported their home language (i.e., "language spoken at home"). Athletes indicating their home language was Spanish were individually matched to athletes that spoke English at home on age, gender, sport, school, and pertinent comorbidities (e.g., concussion history). The final sample included 144 athletes (Spanish home language: n=72, English home language: n=72). DATA COLLECTION AND ANALYSIS: Mann Whitney U tests compared the home language groups (i.e., 19 Spanish vs English) on the Child SCAT5 component scores. RESULTS: Athletes in the Spanish home language group scored lower on the Standardized Assessment of Concussion - Child version (p<.01, r=-.25), Immediate Memory (p<.01, r=-0.45), and Total Modified Balance Error Scoring System scores (p<.01, r=-0.25) compared to the English home language group. CONCLUSIONS: Matched athletes whose home language was Spanish versus English scored differently on baseline Child SCAT5 assessment components. Those with the home language of Spanish scored lower on cognitive and balance tasks compared to those whose home language was English. These findings may serve as rationale for future concussion assessment tools to properly capture clinically relevant data representative language differences among pediatric athletes.

Pilot study to explore girls' lacrosse players' attitudes toward headgear.

Headgear adoption is a controversial issue in girls' lacrosse due to concerns that headgear use will facilitate greater risk-taking by players and contribute to more aggressive game play behaviours. The purpose of this pilot study was to evaluate high school girls' lacrosse players' attitudes towards headgear before and after a season of use. Twenty-five high school girls' lacrosse athletes wore headgear for one competitive season and completed a pre- and post-season survey. The survey evaluated players' attitudes towards headgear use, with Aggressiveness, and Anger scales. Wilcoxon ranked tests were conducted to compare scores pre- and post-season. Players' attitude towards headgear largely remained unchanged and "neutral" after a season of wearing headgear. Players endorsed slightly greater agreement for three Headgear survey items post-season compared to pre-season: " … headgear allows me to be more aggressive … " (p = .01), " … players should wear more protective equipment " (p = .04) and " … wearing headgear increases how often I am hit in the head … " (p = .04). However, Aggressiveness and Anger scale scores were not changed following headgear use. Our findings suggest the perception of headgear use in high school girls' lacrosse is complex and could be associated with minor perceived changes in game play behaviours.

Footwear Type and Testing Environment Do Not Affect Baseline Modified Balance Error Scoring System Performance Among Middle School Athletes.

CONTEXT: Limited evidence exists to demonstrate the effect of extrinsic factors, such as footwear worn or the testing environment, on performance of the modified balance error scoring system (mBESS) in the middle school age (10-14 y) population. Therefore, the purpose of our study was to investigate the effect of footwear types and testing environments on performance of the mBESS by middle school athletes. DESIGN: Cross-sectional. METHODS: In total, 2667 middle school athletes (55.9% boys and 44.1% girls; age = 12.3 [0.94] y) were administered the mBESS while wearing their self-selected footwear (barefoot, cleats, or shoes) either indoors (basketball court) or outdoors (football field or track). The number of errors committed (range = 0-10) during the double-leg, single-leg, and tandem stances of the mBESS were summed to calculate a total score (range = 0-30). Kruskal-Wallis tests were used to assess for differences among the footwear groups for each mBESS stance and the total score. Mann-Whitney U tests with calculated nonparametric effect sizes (r) were used to assess for differences between the footwear groups and testing environments when appropriate. RESULTS: There were significant differences for the number of committed errors among the footwear groups in the single-leg (P < .001) and tandem (P < .001) stances of the mBESS and mBESS total scores (P < .001). Significantly fewer errors (better) were committed while wearing shoes compared with other footwear in the single-leg and tandem stances of the mBESS (Ps ≤ .032, r = .07-.13). Participants assessed indoors committed significantly fewer errors than those assessed outdoors in each stance of the mBESS (Ps ≤ .022, r = .04-.14). Lower (better) mBESS total scores were observed for participants while wearing shoes (Ps ≤ .002, r = .10-.15) or assessed indoors (P = .001, r = .14). CONCLUSIONS: Although our data suggest that the type of footwear worn and the testing environment have a significant effect on mBESS scores of middle school athletes, the magnitudes of these differences are negligible.

Headgear safety attitudes among women's lacrosse stakeholders: Qualitative results.

OBJECTIVE: To explore diverse stakeholders' perceptions of headgear use in collegiate women's lacrosse. PARTICIPANTS: 189 collegiate women's lacrosse stakeholders (players: n = 87; coaches: n = 71; officials: n = 32). METHODS: Participants completed online open-ended qualitative questions surrounding headgear use in the sport. Responses were coded by the research team via inductive reasoning. RESULTS: Stakeholders felt that incorporating headgear use into women's lacrosse would increase aggression and change the nature of the sport. Some felt that headgear was important for injury risk mitigation and invoked a need for research and development. Stakeholders raised the need for coaching and officiating improvement as primary injury prevention measures. Players were concerned about esthetics and performance limitations. Finally, many felt that it should be left to player choice to wear headgear or not. CONCLUSION: Most stakeholders invoke concerns of risk compensation and changing the nature of the sport of women's lacrosse, and are in favor of headgear remaining optional.

Headgear safety attitudes: a national survey of collegiate women's lacrosse stakeholders.

Controversy exists among collegiate lacrosse about the use of headgear and whether its use will facilitate greater risk compensation by players and thus contribute to unsafe gameplay. We aimed to characterize the attitudes of headgear among women's collegiate lacrosse stakeholders. A total of 190 women's lacrosse stakeholders (players: n = 87; coaches: n = 71; officials: n = 32) participated in this study. Participants completed a survey surrounding attitudes of headgear in women's lacrosse. Descriptives, multiple regressions, and Kruskal-Wallis analyses compared attitudes surrounding headgear among stakeholder groups. Scales of Headgear Affects Play (ß = -0.38, p < 0.001) and Sports Development and Safety Practices (ß = 0.26, p < 0.05) significantly predicted endorsement on Headgear Safety Attitudes Scale. Among players, Aesthetics (ß = 0.51, p < 0.001) and Intention to Wear Headgear (ß = 0.31, p < 0.05) predicted endorsement on Headgear Safety Attitudes Scale. Stakeholders did not agree if headgear should be worn in women's lacrosse. Items related to sports development, safety and potential changes in gameplay predicted attitudes to headgear safety among all participants.

The Clinical Utility of the Child SCAT5 for Acute Concussion Assessment.

BACKGROUND: The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5 and 12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion. METHODS: Our participants included 34 concussed (21 boys, 13 girls; age = 12.8 ± 0.86 years) and 44 non-concussed (31 boys, 13 girls; age = 12.4 ± 0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes ([Formula: see text]) were calculated to assess the magnitude of difference for each comparison. The diagnostic properties (sensitivity, specificity, diagnostic accuracy, predictive values, likelihood ratios, and diagnostic odds ratio) of each Child SCAT5 score were also calculated. RESULTS: Concussed children endorsed more symptoms (p < 0.001, [Formula: see text]=0.45), higher symptom severity (p < 0.001, [Formula: see text]=0.44), and had higher double leg (p = 0.046, [Formula: see text]=0.23), single leg (p = 0.035, [Formula: see text]=0.24), and total scores (p = 0.022, [Formula: see text]=0.26) for the mBESS than the non-concussed children. No significant differences were observed for the SAC-C scores (p's ≥ 0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC = 0.76-0.77), negative predictive values (NPV = 0.84-0.88), and negative likelihood ratios (-LR = 0.22-0.31) of the Child SCAT5 scores. CONCLUSIONS: Clinicians should prioritize interpretation of the symptom evaluation form of the Child SCAT5 as it was the most effective component for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion.

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.

Interpreting change on the Child Sport Concussion Assessment Tool 5th Edition.

OBJECTIVES: The purpose of this study was to examine the one-year test-retest reliability of Child Sport Concussion Assessment Tool 5th Edition component scores and provide recommendations for interpreting change on its component tests. DESIGN: A prospective cohort study was conducted across two years via the Advancing Healthcare Initiatives for Underserved Students (ACHIEVES) Project. METHODS: Participants were 219 children (ages 11 to 12, M = 11.7, SD = 0.5; 52.1% girls, 47.9% boys) playing competitive school-sponsored sports in nine middle schools across a large public-school division in Virginia, USA during the 2017-2018 and 2018-2019 academic years. Athletic Trainers administered the baseline Child Sport Concussion Assessment Tool 5th Edition each year. RESULTS: Test-retest reliability estimates for each Child Sport Concussion Assessment Tool 5th Edition component were low to moderate (ICCs=0.40-0.55). A minority of middle school athletes (15-31%) scored within a different normative classification range upon re-assessment. The following test-retest difference scores occurred in 20% or fewer of the sample: +5 total symptoms, +7 symptom severity, -2 in the Standardized Assessment of Concussion - Child Version total score, and +4 total Modified Balance Error Scoring System balance errors. CONCLUSIONS: Child Sport Concussion Assessment Tool 5th Edition component scores had poor to moderate test-retest reliability coefficients over a one-year period, though most children were classified as falling within the same interpretive category upon re-testing based on local norms. We report the raw score changes that were uncommon in our sample of uninjured children to help clinicians identify changes that might be clinically meaningful.

Child Sport Concussion Assessment Tool 5th Edition: Normative Reference Values in Demographically Diverse Youth.

OBJECTIVES: Examine sociodemographic differences (gender, age, and language spoken at home) on baseline Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) scores and establish normative reference data for the Child SCAT5 among middle school student athletes. DESIGN: Cross-sectional study. SETTING: Nine middle schools in Virginia. PARTICIPANTS: A sample of 1355 athletes playing competitive school-sponsored sports (ages 11-13, M = 12.3 ± 0.8; 40.1% girls, 59.9% boys) during the 2017 and 2018 school year. Certified athletic trainers administered the Child SCAT5 within the first 2 weeks of the sport season. INDEPENDENT VARIABLES: Self-reported gender, age, and language spoken at home. MAIN OUTCOME MEASURES: All Child SCAT5 outcome measures. RESULTS: Gender, age, and language spoken at home were associated with Child SCAT5 scores, but the magnitude of differences was generally small. Specifically, girls endorsed more symptoms (girls: M = 8.4 ± 5.7, boys: M = 7.5 ± 5.7; P = 0.003) and greater symptom severity (girls: M = 11.6 ± 9.4, boys: M = 10.4 ± 9.3; P = 0.006) than boys and performed slightly better than boys on cognitive and balance tasks. Older students performed slightly better than younger students on tests of cognition (eg, SAC-C: 11-year-olds: M = 21.3 ± 2.1, 13-year-olds: M = 21.7 ± 2.1; P = 0.02). Total symptoms (P = 0.01), symptom severity (P = 0.01), immediate memory (P < 0.001), delayed recall (P = 0.001), and SAC-C total scores (P = 0.002) differed across language groups. CONCLUSIONS: Gender, age, and language spoken in the home are associated with baseline scores on multiple components of the Child SCAT5 among middle school students, although the magnitudes of observed differences are small. Normative reference values are provided for clinicians when interpreting Child SCAT5 scores.

Middle School Children With Attention-Deficit/Hyperactivity Disorder Have a Greater Concussion History.

OBJECTIVE: Examine lifetime history of concussions in middle school student athletes who have attention-deficit/hyperactivity disorder (ADHD). DESIGN: Cross-sectional study. SETTING: Nine middle schools in Virginia, USA. PARTICIPANTS: A sample of 1037 middle school students (ages 11-14 years, M = 12.6, SD = 0.93; 45.8% girls) underwent baseline/preseason assessments during the 2017 to 2018 academic year and self-reported their health history, including whether or not they had been diagnosed with ADHD. Athletes were divided into 2 groups, those with ADHD (n = 71; 6.8%) and control subjects (n = 966). INDEPENDENT VARIABLES: Self-reported diagnosis of ADHD and self-identified sex. MAIN OUTCOME MEASURES: Self-reported concussion history. RESULTS: In the total sample, boys were more likely to report a previous history of concussion than girls [χ2(1) = 10.81, P = 0.001; odds ratio (OR) = 1.92; 95% confidence interval (CI), 1.30-2.85]. The rate of previous concussion in children with ADHD (23.9%) was twice the rate of previous concussion among children without ADHD (11.4%) [χ2(1) = 9.70, P = 0.002; OR = 2.45; 95% CI, 1.37-4.38]. Approximately 1 in 4 boys with ADHD (24.5%) and 1 in 5 girls with ADHD (22.2%) reported having sustained one or more previous concussions. CONCLUSIONS: Attention-deficit/hyperactivity disorder is associated with a greater prevalence of previous concussion in middle school children. Further research is needed to understand the risk of sustaining concussion for young athletes with ADHD, as well as short- and long-term outcomes of concussion among young athletes with ADHD.

The Effects of Headgear in High School Girls' Lacrosse.

BACKGROUND: Girls' lacrosse headgear that met the ASTM International performance standard (ASTM F3137) became available in 2017. However, the effects of headgear use on impact forces during game play are unknown. PURPOSE: To evaluate potential differences in rates, magnitudes, and game-play characteristics associated with verified impacts among players with and without headgear during competition. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 49 female high school participants (mean age, 16.2 ± 1.2 years; mean height, 1.66 ± 0.05 m; mean weight, 61.2 ± 6.4 kg) volunteered for this study, which took place during the 2016 (no headgear; 18 games) and 2017 (headgear; 15 games) seasons. Wearable sensors synchronized with video verification were used. Descriptive statistics, impact rates, and chi-square analyses described impacts and game-play characteristics among players with and without headgear. Differences in mean peak linear acceleration (PLA) and peak rotational velocity (PRV) between the no headgear and headgear conditions were evaluated using a linear generalized estimating equation regression model to control for repeated within-player measurements. RESULTS: Overall, 649 sensor-instrumented player-games were recorded. A total of 204 impacts ≥20g recorded by the wearable sensors were verified with video analysis (102 no headgear; 102 headgear). Most impacts were imparted to the player's body (n = 152; 74.5%) rather than to the player's head (n = 52; 25.5%). Impact rates per player-game did not vary between the no headgear and headgear conditions (0.30 vs 0.34, respectively; impact rate ratio, 0.88 [95% CI, 0.37-2.08]). There was no association between impact frequency by mechanism or penalties administered between the no headgear and headgear conditions for overall or direct head impacts. The generalized estimating equation model estimated a significant reduction in mean impact magnitudes overall (PLA: -7.9g [95% CI, -13.3 to -2.5]; PRV: -212 deg/s [95% CI, -359 to -64]) with headgear relative to no headgear. No game-related concussions were reported during this study. CONCLUSION: Lacrosse headgear use was associated with a reduction in the magnitude of overall impacts but not a significant change in the rate of impacts, how they occur, or how penalties were administered for impacts sustained during competition. Further research is needed with a larger sample and different levels of play to evaluate the consequences of headgear use in girls' lacrosse.

Children with Attention-Deficit/Hyperactivity Disorder Perform Differently on Pediatric Concussion Assessment.

OBJECTIVE: To compare Child Sport Concussion Assessment Tool Fifth Edition (Child SCAT5) performance between uninjured children with attention-deficit/hyperactivity disorder (ADHD) and precisely matched controls without ADHD. STUDY DESIGN: A nested case-control study was conducted within a cohort of middle school athletes (age 11-12 years) who completed preseason testing. Students with ADHD were individually matched to students without ADHD based on age, sex, language spoken at home, number of prior concussions, sport, and school they attended. The final sample included 54 students (27 with ADHD and 27 controls), 38 (70.4%) boys and 16 (29.6%) girls (average age: 11.7 years, SD = 0.5). RESULTS: Children with ADHD reported more symptoms (M = 13.33, SD = 5.69, P < .001) and greater symptom severity (M = 22.59, SD = 1 1.60, P < .001) compared with controls (total symptoms: M = 6.44, SD = 4.96; symptom severity: M = 8.04, SD = 6.36). Children with ADHD performed similarly to controls on the Child SCAT5 cognitive tests. Children with ADHD committed 3 times as many total balance errors (median = 6) than children without ADHD (median = 2) and committed twice as many errors on single leg stance (ADHD median = 4; No ADHD median = 2) (P values < .001). CONCLUSIONS: Children with ADHD endorsed more concussion-like symptoms and performed worse on balance testing during preseason Child SCAT5 assessment compared with matched controls without ADHD. These findings highlight the challenges of interpreting Child SCAT5 performance in children with ADHD following a concussion or suspected concussion and illustrate the value of administering the measure to children to document their pre-injury performance.