Pre- and Mid-Pandemic Trends During COVID in Concussion Injuries Seen at a University Sport Medicine Clinic

Annie Boyd, BSc,*,† Sheharzad Mahmood, BHSc,* Ann-Marie Przyslupski, MSc,*,† Teresa DeFreitas, MD,*,† Martin Mrazik, PhD, R.Psych,*,‡ and Constance Lebrun, MD*,†

Affiliations: *Glen Sather Sports Medicine Clinic, Edmonton, Alberta, Canada; †Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada; and ‡Department of Educational Psychology, University of Alberta, Edmonton, Alberta, Canada.

Objective: To characterize concussion injuries seen at a university sport medicine clinic in the pre- and mid-pandemic setting.

Study Design: Retrospective chart review of patients with concussion injuries seen by a Sport and Exercise Medicine (SEM) physician at the Glen Sather Sports Medicine Clinic (GSSMC), University of Alberta, Edmonton, Alberta, Canada.

Subjects: Concussion-related visits from January 1, 2015 to May 31, 2021 yielded 552 charts with 621 unique injuries (358M:263F and mean age of 20 ± 9 years).

Observation Technique: Pre-pandemic defined as January 1, 2015 to February 29, 2020 and mid-pandemic as March 1, 2020 to May 31, 2021.

Outcome Measures: Incidence, method of injury and severity (measured by Sport Concussion Assessment Tool (SCAT3/5)).

Results: A total of 579 pre and 42 post pandemic concussions were evaluated. Incidence of patient with concussion presenting to the GSSMC decreased over time (−8 ± 12% per year 2015-2019) with a sharp decrease at pandemic onset (−55% 2019-2020). In the pre-pandemic setting all visits were conducted in-person but an increased uptake in telemedicine resulted in 37% of concussion-related visits performed virtually mid-pandemic. Most injuries seen during the pre-pandemic time frame resulted from organized sport (80%). This was significantly higher than during the mid-pandemic (38%, P < 0.001), where most injuries resulted instead from activities of daily life (ADL) (33%) and recreational sport (29%). Concussion severity as measured by SCAT3/5 symptoms and total symptom scores (TSS) did not differ pre-versus mid-pandemic (mean number of symptoms: pre- 12 ± 7 vs mid- 14 ± 6, P = 0.063; mean TSS: pre- 30 ± 26 vs mid- 39 ± 33, P = 0.073), but across all concussion injuries evaluated, those occurring from organized sports were significantly less severe than those through recreational sport or ADL (mean number of symptoms: organized sport:11 ± 7, ADL: 16 ± 5, P < 0.001; recreational sport: 14 ± 6, P = 0.002; mean TSS: organized sport: 28 ± 25, ADL: 46 ± 29, P < 0.001; recreational sport: 39 ± 29, P = 0.002). Severity was not different across all concussion injuries occurring from recreational sport and ADL (symptom score: P = 0.194; TSS: P = 0.355).

Conclusions: Method of concussion injury significantly changed pre-versus mid-pandemic and may be associated with severity of injury. With the onset of the COVID pandemic there was an increase in virtual care.

Acknowledgements: We would like to thank the Department of Family Medicine for their support.

Assessing the Effectiveness of a Cadaveric Workshop in Improving Resident Physicians' Confidence in Performing Ultrasound-Guided Joint Injections

Ahmed Mahdi, BSc, MD, Lydia K. Schultz, BKin, MD, Graham Briscoe, MD, MBA, and Jane Thornton, MD, PhD

Affiliation: Fowler Kennedy Sports Medicine Clinic, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.

Objective: To assess the effectiveness of an educational workshop using a cadaveric specimen in improving resident physicians' confidence in performing ultrasound-guided joint injections.

Study Design: Effectiveness was assessed using a 12-item survey with a 5-point Likert-type scale administered pre- and post-workshop, and analyzed using descriptive statistics. Pre- and post-workshop scores for paired questions were compared using the Wilcoxon signed rank test.

Subjects: Thirteen Family Medicine resident physicians at Western University and 4 supervisors participated in this study.

Intervention: A two-hour educational workshop led by the study team consisted of a didactic presentation, followed by a demonstration of joint assessment using ultrasound and 4 ultrasound-guided joint injections on a cadaveric specimen: acromioclavicular, glenohumeral, suprapatellar recess, and ankle. Participants were then allowed to practice these injections on the cadaver under the guidance of the study team.

Outcome Measures: Our primary outcome measure was confidence performing ultrasound-guided joint injections post-workshop as compared with pre-workshop confidence. Secondary outcome measures included interest in future workshops, and confidence performing landmark-based injections.

Results: Participant confidence significantly increased for all ultrasound-guided joint injections, from 1.85 ± 0.77 pre-workshop to 4.00 ± 0.55 post-workshop (Wilcoxon signed rank test z = −3.12, P = 0.001). Mean confidence performing landmark-based injections of the same 4 joints practiced under ultrasound significantly increased from 2.15 ± 0.77 pre-workshop to 3.92 ± 0.27 post-workshop (Wilcoxon signed rank test z = −3.06 P = 0.002). All study participants indicated they believed the cadaveric workshop was a realistic (61.5% agree, 38.5% strongly agree) and effective (30.8% agree, 69.2% strongly agree) method to learn ultrasound-guided joint injections. Finally, all participants reported interest in participating in a similar workshop again (30.8% agree, 69.2% strongly agree), and would recommend this workshop to their colleagues (15.4% agree, 84.6% strongly agree).

Conclusions: Educational workshops using cadaveric specimens are effective in improving resident physicians' confidence in performing ultrasound-guided, as well as landmark-based, joint injections. The use of ultrasound improves the accuracy of joint injections in the clinic setting, but limitations to implementation in clinical practice include lack of experience, time limitations, and cost. The inclusion of cadaveric workshops as part of residency and fellowship training could be considered to address some of these barriers.

Injuries and Concussions in Canadian Youth Volleyball Players

K Vaandering, BSc,* PH Eliason, PhD,*-‡, K Pasanen, PT, PhD,*,†,††,‡‡ BE Hagel, PhD,*,†,§,¶ CA Emery, PT, PhD,*,†-‖,‡‡ and KJ Schneider, PT, PhD*-‡,**

Affiliations: *Sport Injury Research Prevention Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; §O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; ¶Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; ‖Community Health Sciences, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; **Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; ††Tampere Research Center of Sports Medicine, Urho Kaleva Kekkonen Institute, Tampere, Finland; and ‡‡McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: To describe injury rates (IR), types, and odds of injury and concussion by sex in youth volleyball players.

Study Design: Cross-sectional.

Subjects: Volleyball participants included 193 [64 male, 128 female, 1 prefer not to respond, median age 15.4 (14.7, 16.4)] during year 2 of a large cohort “Surveillance in High Schools and Community Sport to Reduce (SHRed) Concussions.”

Outcome Measures: Participants reported lifetime history of concussion [e.g.“Have you ever had a concussion (either diagnosed or not) or been ‘knocked out’ or had your ‘bell rung’?“] and injuries requiring medical attention or resulting in at least one day missed participation from sport in the past year. Injury rates with 95% confidence intervals adjusted for cluster by team were calculated by sex for overall injury, volleyball injury and concussion. Exploratory logistic regression examined odds of injury and concussion by sex, adjusting for cluster by team.

Results: Fifty-six participants reported a total of 63 injuries in the previous year (29%), with 5 reporting 2 and one reporting 3. Females had a higher all injury rate than males [IRF: 37.5 injuries/100 athletes/year (95% CI: 29.22, 48.12); IRM: 23.44 injuries/100 athletes/year (95% CI: 13.70, 40.10)]. Thirty-two of these were volleyball-related, with 3 reporting 2 [volleyball-related IRF: 21.88 injuries/100 athletes/year (95% CI: 14.33, 33.40); IRM: 6.25 injuries/100 athletes/year (95% CI: 2.35, 16.63)]. The most common injury types were sprain [46.03%, n = 29 (F: 25, M: 4)] and fracture [23.80%, n = 15 (F:12, M: 3)]. The most common injury locations were the ankle [38.10%, n = 24 (F: 19, M: 5)] and knee [12.70%, n = 8 (F: 7, M: 1)]. A lifetime history of concussion was reported by 22.80% of participants [CRF: 36.72 concussions/100 athletes/lifetime (95% CI: 24.09, 55.96); CRM: 26.56 concussions/100 athletes/lifetime (95% CI: 15.89, 44.41)]. There was no difference observed in the odds of injury [ORF/M = 1.98 (95% CI: 0.95, 4.14)] or concussion [ORF/M = 1.09 (95% CI: 0.54, 2.20)] based on sex.

Conclusions: Ankle and knee injuries are common in youth volleyball players, with females reporting a higher proportion. While odds of injury were not statistically significantly different, females reported higher injury rates than males, suggesting further evaluation with targeted prevention strategies may be appropriate.

Beyond the Medals: A Cross-Sectional Study Investigating Retired High Performance Female Athletes' Health

Jane Thornton MD PhD,*,†,‡ Casey Rosen MD,* Jane Yuan,‡ and Mark Speechley PhD*

Affiliations: *Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; †Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada; and ‡Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.

Objective: To describe the long-term outcomes in musculoskeletal, mental, reproductive/endocrinological and cardiovascular health outcomes in retired Canadian female high performance rowing and rugby athletes.

Study Design: Cross sectional, retrospective, survey-based.

Subjects: Seventy-four retired female national team athletes (30 rowing, 44 rugby). The average participant age was 44.6 years and the average age at retirement was 29.4 years.

Observation Technique: Eligible participants were invited to answer a 136-item online questionnaire co-designed with athlete and stakeholder input. Hypotheses were adjusted for sport to control for differences in effects between rowing and rugby.

Outcomes Measures: Primary outcomes included Hip/Knee Disability and Osteoarthritis Outcome Scores, Oswestry Disability Index scores, Generalized Anxiety Disorder–7 and Patient Health Questionnaire–9 scores, rates of menstrual dysfunction and infertility, and rates of specialist-diagnosed/documented cardiac conditions.

Results: Over 80% of respondents rated their current health as above average or excellent, although anxiety (31%) and depression (38%) were common. Most athletes who sustained hip (24%) or knee (46%) injuries during their careers did not experience long-lasting impacts on their physical health. Twenty-one rowers (70%) and 15 rugby players (34%) experienced back pain during their career. Ongoing symptoms, if present, were mild. Two rowers reported a diagnosis of atrial fibrillation. While one in 5 respondents reported menstrual cycle irregularities during their careers, most (75%) who desired pregnancy were successful. The average age of first-time mothers was 3.5 years older than the Canadian average. Most respondents (82%) said they would still choose to compete at the same elite level if they had the chance to do it again. Those that did not cited reasons including delaying childbearing for too long and financial stressors.

Conclusions: These data provide the first assessment of many post-retirement health outcomes of elite female athletes. Athletes identified mental, musculoskeletal, and cardiovascular health as areas of particular concern. This study not only informs the care of an overlooked population of athletes and role models but also focus our preventative efforts, so that more current, former, and future female athletes can more fully experience the positive outcomes associated with elite sport, long after they hang up their gear for good.

Acknowledgements: We thank Mr. Steve DiCiacca and Dr. Kristen Reilly for their research and administrative support.

Abilities in Focus: How Do Physicians Influence Physical Activity in People With Impaired Mobility?

Kirinpreet Dhillon,* Nancy Quinn, PhD,† Elizabeth Woodward, MD, MA,‡ Susan L. Mills, PhD,§ and Ranita H. K. Manocha, MD, MSc¶

*Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada; †School of Kinesiology, Western University, London, Ontario, Canada; ‡Department of Psychiatry, University of British Columbia, Kelowna, British Columbia, Canada; §School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; and ¶Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, Alberta, Canada.

Objectives: To investigate: a) how people with impaired mobility (PIM) perceive physician encounters about physical activity and sport (PAS); and b) how PIM believe these encounters can be optimized.

Study Design: Qualitative methodology involving photo novella and semi-structured interviews.

Subjects: Eight participants (5 male, 3 female) with impaired mobility and lived experience with PAS.

Observation Technique: Participants took photographs addressing the question, “What does sport mean to me?” Semi-structured interviews, guided by the photographs, were conducted.

Outcome Measures: Interview questions explored involvement in and personal attitudes towards PAS, how physicians influenced PAS involvement, and suggestions for physicians to optimize PAS involvement for PIM. Interview transcripts were analyzed using Interpretive Phenomenological Analysis by the first author, with confirmation of findings and analytical decisions through discussions with co-authors.

Results: Data analysis identified 3 superordinate themes: a) ableism in medicine; b) participant perceptions of and expectations for physician support, and c) supportive interactions between physicians and PIM. The concept of ableism in medicine manifested when physicians medicalized disability, “othered” PIM, and trivialized adapted sport. Some participants perceived physicians as absent or dismissive during encounters or possessing very limited knowledge of adapted sport. Regardless, participants considered physicians to be important players in the promotion of PAS. Some participants experienced supportive encounters with physicians around PAS. These encounters were characterized by experiences of equitable treatment (similar to persons without mobility impairments), physicians being knowledgeable or willing to learn about adapted sport, and physicians being genuinely engaged during encounters. Suggestions from participants on how physicians might optimize interactions about PAS in PIM included: a) expanding knowledge of adapted PAS; b) understanding the unique interests and goals of your patient; and c) providing informational support on PAS to PIM.

Conclusions: Ableism in medical encounters may discourage PAS involvement. Given the physical, psychological, and social benefits of PAS for all persons, it is important to identify and consider the negative unconscious biases physicians may bring to encounters around PAS with PIM. PIM identified physicians as valuable sources of knowledge around PAS and believed that with appropriate education, physicians may leverage their medical expertise to support PAS among PIM.

Acknowledgements: This project was supported by the following University of Calgary programs: the Program for Undergraduate Research Experience (PURE), the Faculty of Kinesiology Undergraduate Practicum Course, the Health and Society Undergraduate Research Methods Course, and the Department of Clinical Neurosciences. The University of British Columbia Faculty of Medicine Doctor, Patient, and Society Course, and the G. F. Strong Rehabilitation Centre, Vancouver, British Columbia also supported this research.

Can Clinical Measures Accurately Identify Sport-Related Concussion Diagnosis in Youth Ice Hockey Players?

KJ Schneider PT, PhD,*-¶ JM Galarneau PhD,* GM Schneider PT, PhD,¶,‖ PH Eliason PhD,*-‡ V Lun MD, MSc,§ and CA Emery PT, PhD*-‡, **-§§

Affiliations: *Sport Injury Research Prevention Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; §Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; ¶Evidence Sport and Spinal Therapy, Calgary, AB, Canada; ‖Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; **O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; ††Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; ‡‡Community Health Sciences, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; and §§McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: To evaluate the contribution of Sport Concussion Assessment Tool (SCAT) subcomponents and clinical measures of cervical spine, ocular motor, vestibulo-ocular, dynamic balance, and divided attention in discriminating between uninjured preseason and post-concussion states in youth ice hockey players diagnosed with sport-related concussion (SRC).

Study Design: Diagnostic accuracy study.

Subjects: Youth hockey players (ages 10-17 years) who participated in a cohort study (“Safe2Play” 2013-2018) and completed both preseason and post-SRC measures.

Observation Technique: Players completed a SCAT3/5 and clinical measures at 1) Preseason and 2) Post-SRC at time of diagnosis by a sport medicine physician.

Outcome Measures: SRC was defined as per the fourth/fifth Consensus on Concussion in Sport (McCrory et al 2013/2017). SCAT3/5 subcomponents [eg, symptom severity score (SSS,/132), modified balance error scoring system (mBESS,/30), etc] and additional clinical measures [i.e., cervical range of motion (ROM; full/limited), cervical flexor endurance (CFE; seconds), cervical flexion rotation test (CFRT; positive/negative), anterolateral cervical spine strength (CSpStrength; lbs), head perturbation test (HPT;/8), extra-ocular motion (EOM; normal/abnormal), head thrust test (HTT; positive/negative), clinical dynamic visual acuity (DVA; logMAR), Functional Gait Assessment (FGA;/30), Walking while talking test (WWTT difference between normal walking time and task of dividing attention, seconds)] were completed by a physiotherapist/athletic therapist. Individual test diagnostic accuracy statistics were calculated and used to inform selection of variables for a multivariate model, with a cut point for correctly classifying concussion of 55%.

Results: A total of 184 youth hockey players (154 male, 30 female, ages 10-17) completed both preseason and post-SRC measures. A model including SSS, mBESS, cervical ROM, CFRT, CFE, CSpStrength, FGA, HTT, and WWTT difference possessed a sensitivity = 0.77; specificity = 0.87; Likelihood ratio (LR)+ = 5.80, LR− = 0.26, and Area under the curve = 0.88 for discriminating between preseason state and SRC-diagnosis.

Conclusions: The diagnostic accuracy of a combination of SCAT5 measures (SSS, mBESS) and additional clinical measures (cervical, VOR,FGA, divided attention) was high based on Se and Sp in discriminating between preseason state and SRC-diagnosis in youth hockey players. Future research is warranted to inform the utility of these measures to diagnose SRC in the absence of preseason measures.

Acknowledgements: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge the funding from Canadian Institutes of Health Research, Alberta Innovates Health Solutions, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation (Integrated Concussion Research Program). Carolyn Emery holds a Canada Research Chair in Concussion. We would like to acknowledge Hockey Canada, Hockey British Columbia, Hockey Edmonton, Airdrie Minor Hockey Association, Hockey Calgary, and all team safety designates, coaches, players, and parents involved for their time and support in completing this research project.

The Free Achilles Tendon is Longer in Those With Midportion Achilles Tendinopathy

Joanne H. Callow, BSc, Mark Cresswell, MD, Faraz Damji, MSc, Joshua Seto, BSc (cand), Antony Hodgson, PhD, and Alex Scott, PhD

Affiliation: University of British Columbia, Vancouver, BC, Canada.

Objective: To compare the free Achilles tendon dimensions between those with midportion or insertional Achilles tendinopathy (AT) and healthy controls using magnetic resonance imaging (MRI).

Study Design: Case-control study.

Subjects: Sixty-six subjects diagnosed with AT (25 insertional and 41 midportion) and 66 matched age-, sex- and weight-matched controls.

Observation Technique: The Achilles tendon dimension were measured using 3D Slicer. All measurements were assessed twice and the mean was reported.

Outcome Measures: The primary outcome measure was free Achilles tendon length. Secondary outcome measures included cross-sectional area (CSA), anteroposterior thickness and location of pathology.

Results: Midportion AT cases had significantly longer free tendons (Mdn = 51.2 mm, IQR = 26.9 mm) compared to controls (Mdn = 40.8 mm, IQR = 20.0 mm), P = 0.007. However, there was not a significant difference between the free Achilles tendon lengths in insertional AT cases (Mdn = 47.9 mm, IQR = 15.1 mm) and controls (Mdn = 39.2 mm, SD = 17.9 mm), P = 0.158.

Conclusions: Having a long free Achilles tendon is associated with the presence of midportion Achilles tendinopathy.

Body Checking Experience is Not Protective of Injury and Concussion Rates in Youth Ice Hockey Players Playing in Body Checking Leagues

Paul H. Eliason, PhD,*-§ Brent E. Hagel, PhD,*-‡,¶,‖ Luz Palacios-Derflingher, PhD,*,¶,** Vineetha Warriyar KV, PhD,* Stephan Bonfield, MSc, MA,* Amanda M. Black, CAT(C), PhD,*-§ Shelina Babul, PhD,†† Martin Mrazik, PhD,‡‡ Constance Lebrun, MD,§§ and Carolyn A. Emery, PT, PhD*-‖

Affiliation: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada; ‡O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; §Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; ¶Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; ‖Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; **Australian Health Services Research Institute (AHSRI), Faculty of Business and Law, University of Wollongong, Wollongong, NSW, Australia; ††British Columbia Injury Research and Prevention Unit, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; ‡‡Faculty of Education, University of Alberta, Edmonton, Alberta, Canada; and §§Family Medicine, Faculty of Medicine and Dentistry and Glen Sather Sport Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada of Alberta, Edmonton, Alberta, Canada.

Objective: To evaluate the association between years of body checking experience and rates of injury and concussion among Under-15 (ages 13-14) and Under-18 (ages 15-17) ice hockey players who play in leagues permitting body checking.

Study Design: Prospective cohort study.

Subjects: Under-15 and Under-18 ice hockey players participating in leagues where policy allowed body checking were recruited into a longitudinal cohort.

Observation Technique: Years of body checking experience were classified based on national and regional body checking policies by season.

Outcome Measures: Game-related injuries were identified using a validated injury surveillance methodology. For any suspected concussion, players were referred to a study sport medicine physician for diagnosis and management. Multiple multilevel Poisson regression analyses were performed, adjusting for important covariables (ie, previous injury/concussion, year of play, level of play, player weight, position) and random effects at a team and individual level (offset by game-exposure-hours), to estimate all injury (IRRI) and concussion incidence rate ratios (IRRC).

Results: In total, 1647 Under-15 (1842 player-seasons) and 941 Under-18 players (1168 player-seasons) participated. Body checking experience was classified into 0, 1, or 2+ years for Under-15 s, and ≤2 or ≥3 years for Under-18 s. No significant differences were found in the adjusted IRRs for injury or concussion for Under-15 players with 1 year (IRRI = 1.06; 95% CI: 0.77-1.45; IRRC = 0.92; 95% CI: 0.59-1.42) or 2+ years of experience (IRRI = 1.16; 95% CI: 0.74-1.84; IRRC = 0.69; 95% CI: 0.38-1.25), relative to those players with no experience. Under-18 players with ≥3 years had higher rates of injury (IRRI = 2.62; 95% CI: 1.61-4.24) and concussion (IRRC = 2.63; 95% CI: 1.31-5.29), relative to those with ≤2 years.

Conclusion: No differences were found in the rates of injury and concussion among Under-15 players with and without body checking experience, whereas Under-18 players with more body checking experience had higher rates of injury and concussion. These findings suggest that body checking experience does not protect against injury or concussion and there are no unintended injury consequences associated with policy restricting body checking in youth ice hockey.

Acknowledgements: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge the funding from Canadian Institutes of Health Research, Alberta Innovates Health Solutions, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation (Integrated Concussion Research Program). Carolyn Emery holds a Canada Research Chair in Concussion. We would like to acknowledge Hockey Canada, Hockey British Columbia, Hockey Edmonton, Airdrie Minor Hockey Association, Hockey Calgary, and all team safety designates, coaches, players, and parents involved for their time and support in completing this research project.

Epidemiological Description of Illness and COVID-19 incidence in High School Athletes and the Risk of Subsequent Injury

Garrett S. Bullock, PT, DPT, DPhil, Charles A. Thigpen, PT, PhD, Albert Prats-Uribe, MD, MPH, FFPH, Tyler Norhen, ATC, Trey Staley, ATC, and Ellen Shanley, PT, PhD, OCS

Affiliation: Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States; ATI Physical Therapy, Greenville, South Carolina, United States.

Objective: 1) Describe illness and COVID-19 specific illness in high school athletes prior to and during the COVID-19 academic school years; 2) Describe and assess the risk of subsequent injury following illness and primary injury.

Study Design: Retrospective Ecological Cohort.

Subjects: 98 487 and 72 521 high school athletes from 6 states participated in the pre-pandemic and pandemic years.

Observation Technique: High schools were matched between pre-pandemic and pandemic year. Illness, initial injury, and subsequent injury incidence proportion (IP) with 95% confidence interval (95% CI) was calculated per 100 athletes. Due to the Center of Disease Control and Prevention guideline of all COVID-19 cases requiring at least 10 to 14 days of isolation; thus, only illnesses that were moderate or severe were included in the subsequent injury analyses. To match similar time loss injuries, only moderate or severe initial injuries were also included for subsequent injury risk analyses. Risk ratios were calculated for subsequent injury following illness or initial injury. Due to the changes in sport participation between during the pandemic, calculations were stratified by pre-pandemic and pandemic years.

Outcome Measures: Athletes presenting with any illness or injury and resulted in time-loss during a team-sponsored practice or game. A COVID-19 illness was defined as a positive test from a medical provider. Illness and injuries were defined as initial and subsequent, and overall, moderate, and severe.

Results: Illness IP was less in the pre-pandemic [0.3 (0.2-0.4)] than pandemic [1.1 (1.0-1.2)] year. COVID-19 illness IP was 0.5 (0.4-0.6) in the pandemic year. No difference in risk was observed for subsequent injury between a primary moderate or severe illness or injury [1.1 (0.86-1.4)] in the pre-pandemic year, but decreased risk [0.4 (0.3-0.5)] in the pandemic year.

Conclusions: Subsequent injury risk was similar for initial moderate or severe illness and injury in the pre-pandemic year; however, there was no difference in the pandemic year. This may be related to increase baseline injury risk following the abrupt high school sport stoppage. Sport clinicians should potentially consider moderate or severe illness similar to an injury, and perform similar return to sport testing.

Can Referees Assess Head Contact Penalties Correctly in Canadian Youth Ice Hockey? A Video Analysis Study

Rylen A. Williamson,* Ash T. Kolstad, MSc,*,† Paul Eliason, PhD,*,†,§,‖ Brent E. Hagel, PhD,*-‖ and Carolyn A. Emery, PT, PhD*-‖

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada; †Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; ‡Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; §Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; ¶O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and ‖Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.

Objective: Concussion rates in ice hockey are among the highest across youth sports. The “zero tolerance for head contact (HC)” policy was implemented throughout Canadian leagues, aiming to reduce the rates of HCs and concussions. However, studies have shown limited effectiveness and referee policy enforcement. Research was warranted to examine referee knowledge, rule enforcement behaviours, and penalty assessment practices. We aimed to examine concurrent validity and inter-rater reliability of youth ice hockey referees' ability to assess HCs and associated penalties using videos of potential penalty infractions.

Study Design: Cross-sectional.

Subjects: From Hockey Alberta, 145 certified level II-III ice hockey referees were recruited.

Intervention: An online survey and secure video file with 60 videos (10-15 seconds) containing a player-to-player contact with or without a HC from U15 (ages 13-14) elite game footage.

Outcome Measures: Survey questions were completed by all referees for each video, including: 1. “Did you see a player-to-player contact? 2. Should a penalty be assessed? 3a. If yes, which player?”, 3b. Which penalty type (eg, HC penalty, tripping)? and 3c. Which penalty intensity (eg, minor, major)? Referee demographics included age, gender, injury history, playing experience, refereeing experience, and certification level. Survey results were used to examine concurrent validity in comparison with a consensus agreement from 2 national and member (top level) gold standard referees. Inter-rater reliability was evaluated using Fleiss Kappa and percent agreement.

Results: Based on complete case analysis of 100 referees, the overall median referee agreement with the gold standard was 83.5% (IQR: 58.7, 95.1), with 85.1% (IQR: 51.7, 96.2) for HC infractions. Inter-rater reliability demonstrated 74.3% [ҡ = 0.472 (0.381-0.562)] agreement on whether a penalty should be assessed and 75.8% [ҡ = 0.366 (0.162-0.570)] agreement on HC penalties. When a HC penalty should have been assessed, penalty type agreement with the gold standard was 81.5% (IQR: 62.7, 95.6), followed by penalty intensity at 53.7% (IQR: 47.2, 64.5).

Conclusions: Referees accurately identified 85.1% of HC infractions and 83.5% of all infractions compared with gold-standard assessment. The level of knowledge for HC-related penalty assessment is high, and the limitation of HC policy enforcement may be related to game factors (eg, game management, positioning), which is an area for future investigation.

Acknowledgements: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding from Canadian Institutes of Health Research, National Football League Scientific Advisory Board Play Smart Play Safe Program, Alberta Innovates Health Solutions, Hotchkiss Brain Institute and Alberta Children's Hospital Foundation. Carolyn Emery is supported by a Canada Research Chair (Tier 1) in Concussion. We acknowledge Hockey Canada, Hockey Alberta, and Hockey Calgary, along with the participant referees from across Alberta.

Imaging Trends for Low Back Pain: Using Linked Population Data to Inform Higher Value Care

Gwyneth de Vries MSc MD,* Chandy Somayaji, MSc,† and J. Ted McDonald PhD‡

*Memorial University of Newfoundland, Fredericton New Brunswick, Canada; and †,‡University of New Brunswick,Fredericton New Brunswick, Canada.

Objective: Exercise is considered high value care for low back pain, yet low-value care (diagnostic imaging) is prevalent. The Choosing Wisely recommendation is “Do not perform imaging for lower back pain unless red flags are present”. To facilitate transition to higher value care, we examined spine imaging trends in New Brunswick (NB).

Study Design: A registry of NB lumbar spine imaging (n = 410 000) from 2011 to 2019 inclusive was transferred to a secure research platform. Pseudonymized data included linkable institute identifiers, and the type, location and date of imaging.

Subjects: Patients 19 and older. Exclusions: procedure-related data and out-of-province patients.

Observation Technique: We verified categories of X-ray, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). Red flags were identified by ICD-10 code-related criteria. We derived annual age- and sex-standardized rates of imaging per 100 000 population.

Outcome Measures: We investigated lumbar spine imaging rates by gender, presence/absence of red flag conditions, imaging type, hospital admissions, physician visits, rurality and socioeconomic status.

Results: Females had 23% more imaging than males. Imaging for plausible red flag conditions accounted for about 20% of all imaging. Imaging rates in NB decreased 20% between 2012 and 2019 to about 7800 per 100 000. X-rays accounted for about 70% of all imaging; CT and MRI were about 15% each (variable by zone). Rural patients had 26% higher imaging rates compared to urban patients. Patients in low-income quintiles had higher imaging rates than wealthy quintiles. Hospitalizations and physician visits were higher in patients post-lumbar spine imaging. Imaging varied by health zone and by the 2 health regions in NB; imaging rates were 46% higher in the health region that does not have tertiary-care spine programs.

Conclusions: We linked spine imaging data with population demographic data to identify variations in lumbar spine imaging. We hope that high value care recommendations (eg exercise) will replace low-value routine imaging in certain groups while recognizing that geography, infrastructure, and availability/distribution of health-care personnel are important factors to consider.

Barriers and Facilitators to Implementing a National Injury and Health Surveillance System for Varsity Athletes in Canada

Taffin S. Evans, CAT(C), BKin,*-§ Gina Dimitropoulos, PhD,†-¶ Kathryn J. Schneider, PT, PhD,*-‡,‖ and Amanda M. Black, CAT(C), PhD*-§

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; §O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; ¶Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada; and ‖Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Evidence Sport and Spinal Therapy, Calgary, Alberta, Canada.

Objective: To understand the barriers and facilitators to implementing an injury and health surveillance system at the varsity level in university institutions across Canada.

Study Design: Qualitative methods including semi-structured interviews with therapists and administrators at Canadian varsity institutions.

Subjects: Male and female athletic therapists/physiotherapists and athletic department staff (n = 12) interested in participating in the first year of surveillance for the Canadian Integrated Injury and Health Surveillance System (Can-IIHSS) were invited via email.

Observation Technique: The Can-IIHSS uses universities' current electronic medical recording (EMR) systems to collect information on pre-participation examination, baseline measures of anxiety (ie, General Anxiety Disorder-7), depression (ie, Patient Health Questionnaire-9), baseline and post-concussion measures, injury information and sport participation exposure. We conducted semi-structured interviews lasting between 60 and 90 minutes with therapists and athletic department staff (ie, varsity sport director) via Zoom. The interview guide was informed by the Consolidated Framework for Implementation Research (CFIR) and focused on barriers and facilitators to implementing the Can-IIHSS.

Outcome Measures: We used qualitative content analysis within a pragmatic worldview to analyze the data deductively to CFIR (key constructs include inner and outer setting, intervention characteristics, individual characteristics, and process) and then coded themes inductively describing barriers and facilitators.

Results: Some important key constructs from CFIR related to barriers and facilitators to implementation identified by participants included relative advantage, evidence strength & quality, cost, compatibility, adaptability, and structural characteristics. Some specific barriers identified included not being able to chart injuries properly because of lack of injury codes available, and a limited number of therapists to number of athletes at institutions therefore not being able to collect all the components of the Can-IIHSS because of the lack of time. Some examples of facilitators to Can-IIHSS implementation included having Canadian specific data to inform clinical practice, and the capability to adjust the EMR.

Conclusions: The Can-IIHSS addresses a key research gap in Canadian varsity injury data collection. Findings highlight important considerations for addressing barriers and augmenting facilitators for successful implementation of this system. Implementing the Can-IIHSS will inform targeted access to resources for therapists, injury prevention strategies, and interventions to improve rehabilitation.

Acknowledgements: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding from the O'Brien Institute for Public Health.