Prevention and Management of Concussions in Youth Ice Hockey: Policy, Education, Beliefs and Behaviours

Home , Concussions in sport, Rugby World Cup Sevens

University of Calgary PRISM: University of Calgary's Digital Repository

Graduate Studies The Vault: Electronic Theses and Dissertations

2017 Prevention and Management of Concussions in Youth Ice Hockey: Policy, Education, Beliefs and Behaviours

Black, Amanda Marie

Black, A. M. (2017). Prevention and Management of Concussions in Youth Ice Hockey: Policy, Education, Beliefs and Behaviours (Unpublished doctoral thesis). University of Calgary, Calgary, AB. doi:10.11575/PRISM/27427 http://hdl.handle.net/11023/3798 doctoral thesis

University of Calgary graduate students retain copyright ownership and moral rights for their thesis. You may use this material in any way that is permitted by the Copyright Act or through licensing that has been assigned to the document. For uses that are not allowable under copyright legislation or licensing, you are required to seek permission. Downloaded from PRISM: https://prism.ucalgary.ca

UNIVERSITY OF CALGARY

Prevention and Management of Concussion in Youth Ice Hockey:

Policy, Education, Beliefs and Behaviours

Amanda Marie Black

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIRMENTS FOR THE

DEGREE OF DOCTOR OF PHILOSOPHY

GRADUATE PROGRAM IN KINESIOLOGY

CALGARY, ALBERTA

APRIL, 2017

Abstract

Sport-related concussions are a major health problem in youth sport and recreational activities. In youth ice hockey specifically, concussion is the most common injury resulting in medical attention or time loss from sport. Concerns surrounding the negative consequences associated with inappropriate management of concussion have resulted in a number of government and sporting organization recommendations for concussion education as a secondary injury prevention strategy. The rationale for this recommendation is that providing education will result in appropriate management following a suspected sport-related concussion (e.g., removal from play assessment by a qualified healthcare professional, full recovery, safe return to sport). Under this assumption, education can mitigate the potential long-term effects of an athlete continuing to play through the injury. This includes the potential prevention of prolonged recovery, long-term health consequences, and in rare cases death. There is evidence to suggest that concussion education may increase participant knowledge, but there is limited research regarding the effect of education on concussion-related beliefs and management behaviour. More research on the effectiveness of concussion prevention strategies is needed. In this dissertation, the burden of concussion across sports (including youth ice hockey) and primary and secondary concussion prevention strategies are described. A qualitative examination of the context of concussion management suggests barriers not typically addressed in conventional education programs can affect concussion management. Further, the association between receiving concussion education and concussion knowledge, beliefs and behaviours under the scope of a behaviour change theory are examined. Increases in knowledge among players, parents and coaches involved with youth ice hockey were found; but had little to no effect on concussion beliefs and concussion management behaviour. However, a national policy change in youth ice hockey delaying the age when body checking is introduced until age 13, resulted in a 64% reduction in the risk of concussion for 11-12 year old hockey players. Rule changes that modify evidence-informed risk factors for a specific sport are an effective means of concussion risk reduction. Further, research examining educational

ii strategies targeting player, parent, and coach beliefs about concussion management and interventions that address barriers to management are needed.

iii Acknowledgements

Completing a PhD is a journey. There are highs and there are lows. There are good times and there are bad times. There are times of excitement and times of apathy. This whole process of working towards my doctoral degree would not have been the same without the many people in my life who have motivated me, inspired me, pushed me to my limits, picked me up when things got tough, or were just there when I needed someone to talk to or be excited with.

First and foremost I have to acknowledge that this PhD project would not have been possible without the support and mentorship of my supervisor, Dr. Carolyn Emery. I cannot thank her enough for believing in me, inspiring me, pushing me to the limits of my abilities and providing me with the amazing opportunities I was able to have throughout my doctoral degree.

I feel incredibly fortunate to have had an amazing mentorship team throughout this whole process. Thank you to my committee members: Dr. Alberto Nettel-Aguirre, Dr. Keith Yeates, Dr. Shelina Babul and Dr. Mariana Brussoni for your support and mentorship throughout this process. I also have to thank my unofficial mentorship team: Bonnie Sutter, Dr. Luz Palacios-Derflingher, Dr. Kathryn Schneider, Dr. Brent Hagel, Dr. Willem Meeuwisse, Dr. Tobi Omu, Dr. William Bridel, Dr. Carly McKay, Dr. Tracy Blake and Dr. Elaine Little. I am forever in your gratitude for the support and wisdom you have provided me throughout my PhD.

I have to acknowledge the research staff, coordinators, lab mates and students at SIPRC and the sport medicine centre who have been my family away from home throughout my 4.5 years in Calgary. This type of research program would never have been possible without your hard work and dedication. I have to acknowledge my long-term lab mates, Paul Eliason and Maciek Krolikowski. You both have definitely made my time here interesting. Also a special thank you goes to Regan McLeod. It has been an honour to mentor you for 2 years, thank you for your contributions to my project.

Finally, I would not be who I was today if it wasn’t for my family. To my mom: Thank you for inspiring me, believing in me and being there when I needed you. Going through this PhD process at the same time as you has been a source of comfort. I feel proud to have a mother like you. To my dad: Your hard work ethic and high expectations have pushed me to try and be the best I can be. To my sister: You are the perfect role model of success, grace and intelligence. Thank you for being there when I needed you. Finally to my brother: Thank you for showing me different perspectives and viewpoints on life.

Unfortunately there is not enough space to acknowledge everyone personally by name but I would like to thank everyone who has taken the time to listen, help or provided needed distractions and breaks throughout this whole process.

v Table of Contents

Abstract ...... ii Acknowledgements ...... iv Table of Contents ...... vi List of Tables ...... ix List of Figures ...... x List of Abbreviations ...... xi Chapter 1: Introduction ...... 1 1.1 Background ...... 2 1.2 Concussion Definition, Identification, Management and Prevention ...... 2 1.3 Participants in the Identification and Management of Concussion in Youth Ice Hockey ...... 4 1.4 Research Rationale ...... 4 1.5 Aims of this PhD Research Program ...... 5 1.6 Summary of Dissertation Format ...... 5 1.7 Summary and Significance ...... 6 Chapter 2: What is the Scope of the problem? Concussion Incidence, Risk Factors and Prevention ...... 8 2.1 Chapter Summary ...... 9 2.2 Concussion Incidence: How common are concussions? ...... 9 2.3 Sport Specific Considerations, Prevalence and Risk factors: What is the risk and severity of concussion in my sport? ...... 12 2.3.1 American Football ...... 12 2.3.2 Australian Football ...... 13 2.3.3 Baseball ...... 13 2.3.4 Basketball ...... 14 2.3.5 Cheerleading ...... 14 2.3.6 Field Hockey ...... 15 2.3.7 Gymnastics ...... 16 2.3.8 Ice Hockey ...... 17 2.3.9 Lacrosse ...... 18 2.3.10 Mixed Martial Arts ...... 19 2.3.11 Rodeo ...... 20 2.3.12 Rugby League ...... 21 2.3.13 Rugby Sevens ...... 22 2.3.14 Rugby Union ...... 22 2.3.15 Soccer ...... 23 2.3.16 Softball ...... 24 2.3.17 Volleyball ...... 24 2.3.18 Wrestling ...... 25 2.4 Key risk factors – how do I identify athletes at risk? ...... 26 2.5 Sport-concussion Prevention: What can be done to prevent concussions? ...... 28

vi 2.5.1 Does protective equipment work? ...... 29 2.5.2 Rule changes and rule enforcement ...... 30 2.5.3 Coaching, neck strength, training, nutrition, and encouraging safe behaviours ...... 31 2.5.4 Secondary Prevention: Policy and Concussion Education ...... 33 2.5.5 Tertiary Prevention: Return to sport and prevention of second occurrence ...... 34 2.6 Conclusion ...... 34 Chapter 3: The complexity of concussion management in youth ice hockey: A qualitative study ...... 35 3.1 Background ...... 36 3.2 Methods ...... 37 3.2.1 Participants and Recruitment ...... 37 3.2.2 Data Collection ...... 37 3.2.3 Qualitative Data Analysis ...... 38 3.3 Results ...... 39 3.3.1 Concussion experience in context: Parent ...... 39 3.3.2 Concussion experience in context: Coach ...... 40 3.3.3 Understanding of concussion symptoms and management: Parents and coaches ...... 42 3.3.4 Barriers and facilitators of appropriate management: Removal from play ...... 42 3.3.5 Barriers and facilitators of appropriate management: Physician Assessment ...... 45 3.4 Discussion ...... 47 3.4.1 Conclusions and recommendations for concussion education ...... 48 Chapter 4: Does receiving information about concussion affect concussion management knowledge, beliefs and/or behaviours? Part 1: Youth ice hockey players ...... 49 4.1 Introduction ...... 50 4.2 Methods ...... 52 4.2.1 Sample and Procedure ...... 52 4.2.2 Theoretical Framework ...... 53 4.2.3 Measurement Tool ...... 54 4.2.4 Study Measures ...... 54 4.2.5 Analysis ...... 58 4.3 Results ...... 60 4.3.1 Sources of Concussion Information ...... 61 4.3.2 Concussion Knowledge ...... 64 4.3.3 Constructs of the Health Action Process Approach ...... 66 4.3.4 Self-reported Player Behaviour ...... 69 4.4 Discussion ...... 71 4.5 Limitations ...... 72 4.6 Conclusion ...... 73 Chapter 5: Does receiving information about concussion affect concussion management knowledge, beliefs and/or behaviours? Part 2: Youth ice hockey parents and coaches ...... 74 5.1 Introduction ...... 75 5.2 Methods ...... 77 5.2.1 Sample and Procedure ...... 77 5.2.2 Theoretical Framework ...... 78 5.2.3 Measurement Tool ...... 79 5.2.4 Study Measures ...... 80

vii 5.2.5 Analysis ...... 85 5.3 Results ...... 86 5.3.1 Sources of concussion information ...... 90 5.3.2 Parent and Coach Concussion Knowledge ...... 92 5.3.3 Parent and coach beliefs under the scope of the Health Action Process Approach ..... 94 5.3.4 Self-reported Parent and Coach Behaviour ...... 96 5.4 Discussion ...... 97 5.5 Limitations ...... 98 5.6 Conclusions ...... 100 Chapter 6: The Risk of Injury Associated with Body Checking among Pee Wee Ice Hockey Players: An evaluation of Hockey Canada’s national body checking policy change ...... 102 6.1 Introduction ...... 103 6.2 Methods ...... 104 6.2.1 Design, Sample, and Data Acquisition ...... 104 6.2.2 Statistical Analysis ...... 106 6.2.3 Ethics Approval ...... 107 6.3 Results ...... 107 6.3.1 Game Injury Rates ...... 109 6.3.2 Risk Factors for Injury and Concussion ...... 111 6.3.3 Mechanisms of Injury ...... 113 6.4 Discussion ...... 114 6.5 Limitations ...... 115 6.6 Conclusions ...... 116 Chapter 7: Conclusions and Future Directions ...... 117 References ...... 125 Appendices ...... 159 Appendix A: Concussion Rates Across Sport, Level of Play and Country ...... 160 Appendix B: Qualitative Interview Guide ...... 170 Appendix C Sample Themes and Full List of Quotes ...... 174 Appendix D Summary Statistics and HAPA Construct Items ...... 176 Appendix E Concussion Knowledge Beliefs and Behaviour Questionnaire (CKBBQ): Player Version ...... 181 Appendix F Concussion Knowledge Beliefs and Behaviour Questionnaire (CKBBQ): Parent and Coach Version ...... 185 Appendix G Concussion Knowledge Beliefs and Behaviour Questionnaire (CKBBQ): Coach (Non-Parent) Version ...... 191 Appendix H Preseason Baseline Questionnaire ...... 195 Appendix I Weekly Exposure Sheet ...... 199 Appendix J Injury Report Form ...... 200 Appendix K Copyright Permission Letter ...... 204

viii List of Tables

Table 2.1 Risk of concussion in different sports by age and sex ...... 11 Table 2.2 Intrinsic and extrinsic risk factors for concussion in different sports ...... 27 Table 2.3 Summary of proposed prevention strategies ...... 29 Table 3.1 Barriers and facilitators to an athlete with a suspected concussion being removed from play ...... 44 Table 3.2 Barriers and facilitators to a parent taking their child for physician assessment and follow-up ...... 46 Table 4.1 Characteristics of study participants ...... 61 Table 4.2 The source and helpfulness of concussion information ...... 63 Table 4.3 Participant knowledge by exposure to previous education ...... 65 Table 4.4 Summary statistics of the Health Action Process Approach constructs by exposure to education ...... 67 Table 4.5 Association between HAPA constructs and education, previous concussion and age group based on multivariate linear regression ...... 68 Table 4.6 Summary of player behaviours by whether or not they received concussion education in the last year ...... 70 Table 5.1 Characteristics of all study participants ...... 88 Table 5.2 The source and helpfulness of concussion information obtained by parents and coaches of youth ice hockey players ...... 91 Table 5.3. Parent and coach knowledge by exposure to previous education ...... 93 Table 5.4 Characteristics of coaches who completed the questionnaire section on coach beliefs ...... 95 Table 5.5 Summary statistics of the Health Action Process Approach constructs related to parent and coach concussion behaviour management ...... 96 Table 6.1 Baseline characteristics comparing Pee Wee (11-12 years) hockey players in the 2011-12 and 2013-2014 ...... 108 Table 6.2 Summary of Game-Related Outcome Variables for Pee Wee ice Hockey Injuries in Calgary ...... 110 Table 6.3 Risk factor analyses for game-related injury, severe injury, concussion and concussion with greater than 10 days time loss in Alberta 2011-12 and 2013-14 ...... 112

ix List of Figures

Figure 4.1 The Health Action Process Approach ...... 54 Figure 4.2 Frequency of self-report preferred sources for concussion education ...... 64 Figure 5.1 The Health Action Process Approach ...... 79 Figure 5.2 Frequency of self-report preferred sources for concussion education by parents and coaches ...... 90 Figure 6.1 Game-related injury rates by injury mechanism and cohort in Pee Wee ice hockey, 2011-2012 and 2013-2014 ...... 113 Figure 7.1 Concussion knowledge by previous history of concussion education and participant group ...... 121 Figure 7.2 Constructs of the Health Action Process Approach by previous history of concussion for players ...... 121 Figure 7.3 Constructs of the Health action Process Approach by previous history of concussion education for parents ...... 122 Figure 7.4 Constructs of the Health Action Process Approach by previous history of concussion education for coaches ...... 122

x List of Abbreviations

95%CI 95% Confidence Interval AE Athlete-Exposure CKBBQ Concussion Knowledge Belief and Behaviour Questionnaire DHA Docosahexanoic acid ED Emergency Department HAPA Health Action Process Approach IQR Interquartile range IRF Injury Report Form KO Knockout MMA Mixed Martial Arts NBA National Basketball Association NCAA National Collegiate Athletics Association P-H Player-Hours PBQ Preseason Baseline Questionnaire TKO Technical Knockout UFC Ultimate Fighting Championship WES Weekly Exposure Sheet

Chapter 1: Introduction

1 1.1 Background Ice hockey is one of Canada’s most popular winter sports. More than 500,000 youth participants register to play with Hockey Canada every year.1 While participation in team sports like ice hockey is positively associated with motor skill development,2 higher self-esteem,3 and increases in perceived health and life satisfaction;4 there is also a high risk of injury. A concussion is one of the most common injuries resulting in medical attention in hockey; accounting for 18 to 66% of all injuries.5–11 Furthermore, a recent systematic review identified ice hockey as having the second highest rate of concussion for children and youth, second to rugby, out of thirteen sports with a pooled incidence rate estimate of 1.20 concussions per 1000 athlete-exposures (AE).12 Sustaining multiple concussions may have long-term consequences for young athletes, including prolonged concussion symptoms, behavioural issues and memory problems.13–16 The consequences may be more severe if the initial recognition of symptoms is missed or the athlete returns to play prior to the resolution of symptoms.17–19 In response to the purported negative consequences of concussion, new concussion legislations have been passed and/or implemented across the United States and the province of Ontario with education as a core tenet. Specifically, appropriate education about prevention, recognition, management and return-to-play has been identified by concussion researchers and sport governing bodies as essential to mitigate the burden of concussion in sporting populations.18–21 While previous research has demonstrated an increase in knowledge and awareness associated with concussion education, the effect of education on management behaviour requires further evaluation.

1.2 Concussion Definition, Identification, Management and Prevention According to the 4th international consensus statement on concussion in sport, a concussion is a brain injury that is defined as a complex pathophysiological process that affects the brain following traumatic biomechanical forces.21 These forces may be applied directly to the head or to the body.21 Symptoms of concussion may be somatic (e.g., headache) cognitive (e.g., difficulty concentrating) or emotional (e.g., sadness) and signs can present as physical signs,

2 behavioural changes, cognitive impairments and/or sleep impairments.21 Sign and symptom development can be rapid or gradual, evolving over minutes or hours.21 Typically, clinical and cognitive symptom resolution follows a sequential course where the majority of concussions resolve in 7 to 10 days.21 However, the recovery time frame may be longer in children and adolescents and there are some cases when symptoms may be prolonged.21–24 Differences in recovery times among young children may be related to the developing brain.25 Data collected from children presenting at the emergency room with a concussion suggests that an estimated 30% of children are still symptomatic at 1 month post-concussion, and 14% of children are still symptomatic at 3 months postconcussion. 23,24 Typically, if there is a mechanism resulting in force applied directly or indirectly to the head and one or more signs or symptoms of concussion is present, then a concussion is suspected and should be managed appropriately.21,26 Based on the 4th International Consensus on Sport Concussion, appropriate management involves identification, immediate removal from play and a referral to a physician for diagnosis.21 Physical and cognitive rest, including no hockey and limited or modified school activity, are recommended followed by a six step graded exertion return-to-play protocol, including clearance by a physician.21 Preventing concussions can be understood across the full spectrum of care. This spectrum consists of primary prevention (preventing the initial occurrence), secondary prevention (early detection) and tertiary prevention (full recovery and prevention of second occurrence). Primary prevention of concussions is challenging because the evidence to support purported prevention strategies has methodological limitations, conflicting evidence, and/or is still theoretical. These commonly promoted prevention strategies include properly fitting equipment (e.g., helmets, mouth guards, head gear), rules and rule enforcement, improving coaching techniques, and promoting respect and fair play.10,27–30 A full overview and critique of prevention strategies will be provided in Chapter 2 of this dissertation.

3 1.3 Participants in the Identification and Management of Concussion in Youth Ice Hockey Parents, players, and coaches all play a role in identifying and ensuring appropriate management of concussion.18,31,32 Early identification is key to preventing the negative consequences associated with continuing to play through a concussion (secondary prevention). In the absence of a medical professional on the sidelines, appropriate management can occur through the following steps: 1) The coach identifies a concussion mechanism has occurred, recognises concussion signs and symptoms, removes the player from play, and alerts the parent to follow-up with a medical professional, 2) The player and/or a teammate report concussion symptoms to the coach and/or parent to help with identification of the suspected concussion, 3) The parent takes their child to be assessed by a physician, who can provide recommendations for recovery, and clear the player for sport participation when it is safe to return to play. Experts postulate that learning about concussions, being able to identify the signs and symptoms of concussion, identifying what mechanisms can cause concussion, knowing how to respond to concussion and how to safely return to play will lead to appropriate management.21 However, the beliefs of parents, players and coaches can affect whether or not they respond appropriately to a suspected concussion or even recognize a suspected concussion occured.33 According to behaviour change theories, these beliefs can include, but are not limited to, the perception of risks of negative outcomes associated with a given behavioural response, the expectation of what will happen if they perform the desired behaviour and perceived confidence in their ability to perform the behaviour.34 Therefore, it is crucial to not only examine how education affects knowledge but also how it affects their beliefs about the behaviour.

1.4 Research Rationale Concussions are a major health concern for youth ice hockey players. If concussions are not managed appropriately there is a risk of more severe consequences, including longer recovery times and severe disability.17,35,36 A gap in coaches’, parents’

4 and players’ understanding of signs and symptoms has been hypothesised as the primary reason concussions are mismanaged and continue to go undetected in youth sports.21 However, players can choose to hide symptoms of a concussion from their parents or coaches and choose to continue to play, coaches can decide not to remove athletes from important games, and parents may not take their child to a physician for clearance prior to returning them to play. Theories of health behaviour change can potentially identify salient motivators and predictors of behaviour but have not been widely used in the concussion literature. Using a behavioural change model as a framework, there is a need to understand how concussion education may influence knowledge and beliefs underlying the behavioural choices that affect how the harmful effects of concussions are prevented and managed in high-risk populations like youth ice hockey players. Given concussion education is currently being implemented using legislation, there is also a need to understand the role legislation and policy plays in the prevention of concussion.

1.5 Aims of this PhD Research Program The overarching aim of this research program is to investigate the association between concussion education and knowledge, beliefs, and behaviours related to the management of concussion in youth ice hockey using a behaviour change theory. Given that many youth ice hockey teams do not have access to medical professionals on the bench; this project focuses on the knowledge, beliefs and management behaviours of players, coaches and parents. The project further aims to explore the barriers and facilitators to appropriate concussion management as well as the role of policy and legislation in preventing concussion.

1.6 Summary of Dissertation Format This PhD dissertation consists of reviews and original research designed to explore the roles that concussion education and policy play in the prevention of sport- related concussion; using youth ice hockey as an example. Chapter 2 provides the reader with an overview of the burden of concussion in sport, risk factors, and prevention strategies. This chapter was written and submitted for publication in the textbook “Sport Concussion: A Complete Guide to Recovery and Management”. Chapter 3 provides context to understanding the complexity of concussion management experience and the

5 role of education using semi-structured interviews with parents and coaches of youth ice hockey players. The chapter summarizes barriers and facilitators of concussion management. Chapter 4 presents original research on the effect of previous education on knowledge, beliefs and behaviours in youth ice hockey players using the Health Action Process Approach as a theoretical framework. Chapter 5 extends the work on the effect of previous concussion education on knowledge, beliefs and behaviours to a parent and coach population. Chapter 6 provides an example of effective policy implementation for the primary prevention of injuries and concussions in youth ice hockey. This chapter was recently published in the British Journal of Sport Medicine.37 Finally, chapter 7 provides an overview of the findings and discusses recommendations for future educational interventions and the role of policy surrounding education. Chapters 2-6 have been formatted for submission to textbooks or journals as stand-alone manuscripts. As such, information in the introduction and discussion may be repetitive between chapters. Finally, due to page and formatting restrictions of the journals, not all information could be included in the chapters. Therefore, additional details related to methods and results are available in the appendices of this dissertation.

1.7 Summary and Significance Over 500,000 youth participate in youth ice hockey in Canada. Youth sport organizations are implementing concussion educational programs in hopes of better managing and preventing concussion. There is a need to evaluate the effectiveness of these efforts. This research program is the first to examine concussion related behaviours of players, coaches and parents using a behavioural change framework [Health Action Process Approach (HAPA)] that explores post-intentional factors that includes planning and post-intentional self-efficacy. The key to successful behaviour change efforts is to fully understand the determinants of behaviours and to properly apply health behaviour theory to the implementation of interventions.38 The future content of concussion education interventions must be informed by player, coach and parent awareness of signs and symptoms, ability to respond to concussion and awareness of return to play procedures, and understanding of the determinants of behaviour change. The addition of a qualitative research component broadens the depth of our understanding of participant

6 behaviour and different barriers and facilitators of concussion management behaviour. The role of the coach is highlighted because of their potential to mandate education, they can transfer concussion education to both parents and players, and because in many youth leagues they make the final decisions as to who returns to the ice following injury. The role of the parents was examined because of their ability to influence and supervise management and return-to-play. Finally, examining parents, players and coaches within the same framework allows the comparison of the effect of education in each population.

Chapter 2: What is the Scope of the problem? Concussion Incidence, Risk Factors and Prevention

Black AM, Eliason P, Patton D, Emery CA. Chapter 3: Concussion Incidence, Risk Factors and Prevention. In: Sport Concussion: A complete guide to management. CRC Press. Submitted to Editor.

8 2.1 Chapter Summary

The aim of this chapter is to summarize sport-specific concussion rates and incidence proportions across sport and age groups based on epidemiological studies. It will address the following questions— How common are concussions? What is the concussion risk and severity by sport, age group and sex? How can athletes at risk be identified? What can be done to prevent concussions?

2.2 Concussion Incidence: How common are concussions?

Concussion and the consequences of concussion are a significant public health burden, gaining increased attention in the media over the past decade. Estimating how common concussions are across sports is challenging because of the heterogeneity and methodological limitations of the available studies. Different definitions of concussion, different methods of concussion identification (e.g., self-report, medically diagnosed), different settings (e.g., emergency room, sport medicine clinic, family physician office, field), lack of consideration for athlete participation hours, and athlete characteristics can contribute to different estimates of injury risk. Studies that examine concussion burden commonly take one of three forms: (1) community-based cohort studies using prospective surveillance that record the number of concussions and exposure hours over a period of time; (2) hospital-based cohort studies that record the number of concussions and use population and sport-specific participation estimates or consider the proportion of people sustaining concussions that visit the hospital relative to other injuries; and (3) cross-sectional studies examine self-reported history of concussion. While all three study designs provide information about how common concussions are, the most valuable studies are community-based cohort studies using validated injury surveillance that allow us to understand the risk of concussion relative to the amount of time the players are exposed to risk and take into account key

9 risk factors that affect risk (e.g., age, level of play, previous history of concussion/injury, sex). It is important to recognize that concussion rates vary based on what denominator is selected. Depending on the data collected, estimates are presented relative to player- hours exposed (P-H), athlete exposure (AE; one athlete participating in one session), per number of athletes, or as a proportion of all injuries. Concussion identification has been largely dependent on our ability to detect this injury and the methods used have changed over time. Therefore, it is important to note that this chapter will summarize the evidence available regarding sport concussion incidence estimates since 2005. Table 2.1 provides an overview of the ranges of risk estimates of concussion in different sports by age and sex. The highest competition concussion incidence rates were found in primarily contact or collisions sports including American football, Australian football league, ice hockey, rugby, lacrosse, soccer and wrestling. Concussion represented the highest proportion of all injuries in ice hockey representing between 7.9 and 66% of all injuries seen in the sport depending on sex and age group. Appendix A summarizes a complete list of the estimates from different studies by country and sport.

10 Table 2.1: Risk of concussion in different sports by age and sex where available Table 1 2.1 Risk of concussion in different sports by age and sex Sport and age/sex Competition Training Overall Proportion of all (M=male, F=female, incidence1 incidence1 Incidence1 injuries (ED=seen in U=unspecified) emergency department) American Football Professional (M) 6.61(AE) - - - Collegiate (M) 3.01-4.35(AE) 0.42-0.82(AE) 0.37-1.41(AE) 8-21% High School (M) 1.55-2.01(AE) 0.21-0.66(AE) 0.47-0.92(AE) 4-12% Youth (M) 2.38-6.16(AE) 0.24-0.59(AE) 0.61-1.76(AE) 9.6% Australian Football League Professional (M) 1.3-5.6(P-H) - - - Baseball Professional (M) - - 0.42(AE) Collegiate (M/U) 0.12-0.26(AE) 0.03-0.07(AE) 0.07-0.12(AE) 2.5-3.3% High School (M/U) 0.08-0.11(AE) 0.01-0.03(AE) 0.04-0.06(AE) 3-5.5% Basketball Professional (M) 0.2(AE) - - 0.8% Professional (F) 0.6(AE) - - 1.8% Collegiate (M) 0.32-0.61(AE) 0.12-0.34(AE) 0.16-0.39(AE) 3.2-4% Collegiate (F) 0.85-1.09(AE) 0.12-0.44(AE) 0.22-0.60(AE) 4.7-7% High School (M) 0.11-0.39(AE) 0.06(AE) 0.07-0.24(AE) 3-10% High School (F) 0.55-0.60(AE) 0.06(AE) 0.16-0.37(AE) 3.3-19% Cheerleading All Star (U) - - - 1.4% Collegiate (U) - - - 12.5% High School (U) 0.12(AE) 0.14(AE) 0.06-0.14(AE) 5.7-20.7% Field Hockey Collegiate (F) 0.52-1.11(AE) 0.09-0.18(AE) 0.18-0.40(AE) 3.4-9.4% High School (F) 0.41(AE) 0.14(AE) 0.03-0.22(AE) 12% Gymnastics Collegiate (F) 0.48(AE) 0.24(AE) 0.16-0.27(AE) 2.3% High School (F) 0.24(AE) 0.03(AE) 0.07-0.08(AE) 3-3.4% Youth (U-age: 6-17) - - - 1.7%(ED) Ice Hockey Professional (M) 1.8(P-H) - - - Collegiate (M) 2.07-2.49(AE) 0.16-0.25(AE) 0.41-0.79(AE) 7.9% Collegiate (F) 1.78-2.01(AE) 0.29-0.30(AE) 0.66-0.91(AE) 18.3% High School (M) 1.46-1.67(AE) 0.11-0.15(AE) 0.54-0.64(AE) 21-28% Youth (U-12-18) 2.46(AE) 1.17(AE) 2.46(AE) - Midget (U-age:15-17) - - 0.82(P-H) 13% Bantam (U-age:13-14) 0.79(P-H) - 0.53-0.97(P-H) 20-23% Peewee3(U-age:11-12) 1.47-2.73(P-H) - 0.81-1.72(P-H) 25-66% Peewee (U-age:11-12) 0.39-1.82(P-H) - 0.28-0.64(P-H) 25-57% Atom (U-ages: 9-10) - - 0.24(P-H) 13% Lacrosse Collegiate (M) 0.93-2.30(AE) 0.20-0.24(AE) 0.26-0.54(AE) 5.6% Collegiate (F) 0.25-1.50(AE) 0.15-0.26(AE) 0.25-0.52(AE) 4.6-9.8% High School (M) 1.04(AE) 0.11(AE) 0.30-0.40(AE) 17% High School (F) 0.86(AE) 0.13(AE) 0.20-0.35(AE) 21% Rugby Union Professional (M) 0.17-13.8 (P-H) - - - Semi-Professional (M) 2.9-8.4(P-H) - - - Amateur (M) 8.7-11.0(P-H) - - - Collegiate (M) 2.2(P-H) 0.40(P-H) - 8.7-20.0% Collegiate (F) 1.6(P-H) 0.30(P-H) - 15% Youth (M-ages7-18) 0.0-12.7(P-H) - - 16.1% Youth (F) - - - 14.3% Soccer Professional (M) 1.06(P-H) - 0.06(P-H) 0.1%-9% Professional (F) 2.56(P-H) - - - Collegiate (M) 0.97-1.80(AE) 0.17-0.24(AE) 0.28-0.49(AE) 3.9-5% Collegiate (F) 0.97-1.94(AE) 0.21-0.25(AE) 0.41-0.65(AE) 5.3-7% High School (M) 0.59(AE) 0.04(AE) 0.22-0.28(AE) 9.3-9.5 High School (F) 0.79(AE) 0.09(AE) 0.36-0.45(AE) 12.2-15% Middle School (F) 5.3(AE) 0.2(AE) 1.20(AE) - Softball Collegiate (F/U) 0.37-0.56(AE) 0.07-0.17(AE) 0.14-0.33 4.3% High School (F/U) 0.04-0.29(AE) 0.07-0.09(AE) 0.07-9.16 5.5-13% Volleyball Collegiate (F) 0.13-0.56(AE) 0.18-0.27(AE) 0.09-0.36(AE) 2.1-6.4% High School (F) 0.05-0.11(AE) 0.04-0.05(AE) 0.05-0.20(AE) 3-8% Wrestling Collegiate (M/U) 1.0-5.5(AE) 0.35-0.57(AE) 0.35-1.09(AE) 3.3-5.8% High School (M/U) 0.32-0.48(AE) 0.10-0.13(AE) 0.15-0.57(AE) 5.4-10% 1Incidence is reported by adult/youth, male/female, and level of play as the number of injuries per 1000 hours of training and competition (P-H) or per 1000 athlete exposure (AE)

11 2.3 Sport Specific Considerations, Prevalence and Risk factors: What is the risk and severity of concussion in my sport?

2.3.1 American Football

American Football is a play-by-play collision sport with very fast and physical elements. It is primarily played professionally in North America, but several other countries have professional leagues and many more have amateur competitions. Injury rate data have been collected primarily in the United States through the National Collegiate Athletics Association (NCAA) surveillance system, the high school reporting injury surveillance system and through the support of community leagues. Game concussion incidence rates range between 2.01 – 6.61 concussions per 1000AE and concussions represent between 4-21% of all injuries seen in the sport.39–46 Between 1997 and 2008 the rate of concussion in high school football has been increasing annually by an average of 8%.47 It should be noted that the rate of concussion is substantially higher in games than practice across all levels. 40,44–46 In American football, helmets are compulsory, in addition to shoulder, hip and knee pads, with many other optional forms of padding.48 The tackle and block phases are responsible for approximately two-thirds of concussions sustained by high school 43,49 and collegiate50 football players and over three quarters of concussions sustained by professionals.51 Helmet-to-helmet contact is a common mechanism for concussion in American football, which is responsible for 45% of concussions at the youth level44 and over half of all concussions at the high school52 and collegiate53 levels. The National Football League (NFL) is continually implementing rule changes in an attempt to protect players from impacts that may cause concussion.51 In 2013, a class action by more than 4500 retired American football players resolved concussion litigation against the NFL.54 Almost US$800 million was contributed by the NFL to provide medical and other benefits, as well as compensation, to qualifying injured players or their families. A recent pilot study in collegiate football players investigating a helmetless- tackling intervention found that players participating in helmetless-tackling drills during training experienced a 28% reduction in head impact frequency per athletic-exposure over a single season.55

12 2.3.2 Australian Football

Australian football is a fast, kicking and running game played professionally throughout Australia, in addition to amateur level competitions in other countries.56 The Australian Football League (AFL) has commissioned an annual injury surveillance report since 1992 and in 1996 was the first professional sporting body to publically release surveillance injury data.57 Between 2000 and 2009 the concussion incidence rate in professional level AFL has ranged between 5.5-13 concussions per 1000 player hours.58– 60 During the 2014 AFL season, there were approximately 1.3 new concussions per club, which was higher than previous years: 2011-2013, 1.0 new concussions per club; 2008- 2010, 0.5 new concussions per club; 2002-2004, 0.4 new concussions per club.61 AFL rules do not promote head contact. The tackle laws in Australian football require the tackling player to hold the ball-carrier below the shoulders and above the knees. 62 However, video analysis of head injuries occurring in professional AFL have reported that direct head impact during collision or contesting ball possession is still responsible for a large proportion of concussions.63

2.3.3 Baseball

Based on data from the National High School Athletics Participation Survey and the NCAA Sports Sponsorship and Participation Rates Report, approximately 487,000 high school men, 1,200 high school women, and 34,000 collegiate men played baseball in the United States during the 2014-2015 season.64,65 Relative to other sports, the incidence of concussion in baseball is relatively small and accounts for approximately 1-5% of all injuries at the high school level and 2.5% at the collegiate level.8,41,47,66,67 Although the range of concussion rates across studies suggests the concussion rate at the collegiate level may be higher than at the high school level, the difference is not statistically significant.66 Both collegiate and high school athletes sustained a higher rate of concussions in games than practices.8,66–68 Between 1998 and 2008 the rate of concussion in high school baseball has been increasing annually by an average of 14%.47 The mechanism of concussions in amateur baseball typically include head contact with the pitched ball or fielding a batted ball,8,66 while at the professional level, contact between players and fielding a batted ball were the most common mechanisms of

13 concussion.69 This is supported by Cantu & Mueller (2009) who suggest the top three reasons for catastrophic injury in high school and collegiate baseball are related to the athlete being hit by either a thrown or batted ball, the athlete colliding with a teammate while chasing a fly ball, or the athlete using a head first slide technique and makes contact with their head and the opposing players’ lower body or the base.70 At the professional level, catchers were more likely to incur a concussion than any other position,69 which may be due to collisions with runners at home plate.71

2.3.4 Basketball

Basketball is a popular sport played around the world. While the most common injury in basketball is ankle sprain injury, concussions have been reported to represent between 1.8 and 19% of all injuries sustained in basketball.8,72–76 Over the last decade, concussion rates in basketball have increased significantly at all competitive levels from high school to professional players in the NBA.77,78 Basketball accounted for 115/ 4745 sport-related concussion hospitalizations in Victoria, Australia between 2002 and 2011.79 Furthermore, concussions from basketball made up 9.2% of all sport related concussions in youth ages 8-19 in the United States.80 The majority of studies have found that female basketball players have a higher rate of concussion than male basketball players.8,46,77 The most common mechanism of concussion in basketball is player contact while either defending, rebounding or general play.8,46,74 Unfortunately, primary prevention strategies in basketball have not been successful. For example, Labella et al.81 examined the use of mouth guards as a preventive measure for concussion in Division 1 college basketball teams. While they found mouth guard users had lower rates of dental injuries, there were no significant differences in concussion rates between mouth guard users and non-users (RR= 0.63 95%CI: 0.12-2.02). 81

2.3.5 Cheerleading

Cheerleading is a dynamic and complex sport combining dance, gymnastics and individual as well as group stunts. Despite the popularity across North America, injury surveillance data on cheerleading injuries is limited and only available from the United States. Strains/sprains, fractures and contusions are the most common injuries sustained

14 by cheerleaders.82 However, concussions represent between 3.5-20.7% of all injuries in high school cheerleading, 12.5% of all injuries in collegiate cheerleading and 3.5% of cheerleading injuries seen at emergency departments among ages 5-17.8,83–85 The most common activity associated with concussions are stunts with a triple base (i.e., toss, lift).8 In a study examining injury risk in high school cheerleading, 45% of concussions occurred when there was no spotter.8 Different types of cheerleading teams are at different risk of concussion. Shields et al.84 examined stunt-related injuries among cheerleaders participating in five different types of cheerleading teams. They reported that cheerleaders on collegiate teams were more likely to sustain a stunt-related concussion than cheerleaders on all-star or high school teams. Stunt-related concussions were more likely to occur in training sessions than competitions. Finally, fifty percent of stunt-related concussions result in time lost equal to or greater than seven days. 84

2.3.6 Field Hockey

Field hockey is played recreationally by men and women around the world. Data on concussion in field hockey from outside North America or in a male population is minimal and limited to tournament style of play. During the 2008 and 2012 summer Olympic games only 1 concussion was identified among all male and female field hockey athletes.86,87 While, during the 2009 Men’s Junior World Cup there were 5 concussions reported over 58 matches with 3 concussions resulting in the player being removed from the game.88 The majority of available prospective concussion research has been conducted in the high school and collegiate settings in North America where women primarily play the sport. Concussion incidence rates among female field hockey players range between 0.03-0.22 per 1000 AE in high school8,47,89 and between 0.18-0.40 at the collegiate level. The most common mechanism of concussions in women’s field hockey is player to player contact.90 This contact could occur while handling the ball, running, or stick contact during general play.46 In a report of high school concussions in field hockey, 35.3% of concussions were sustained by midfielders, 29.4% were sustained by defenders and 21.6% were sustained by forwards.8 Between 1998 and 2008 the rate of concussion

15 among women’s high school field hockey has been increasing annually by an average of 20%.47 In a study examining 15 sport related concussions in women’s collegiate field hockey, players reported on average 5.93 symptoms following concussion and 20% resulted in players taking greater than 28 days to return to sport.91 Despite more equipment being required for ice hockey than field hockey, concussions are more prevalent among ice hockey players when compared to field hockey players.92 While some field hockey players may choose to wear mouth guards and/or eyewear, facial protective equipment is not mandatory for all players. In 2011, The National Federation of State High School Associations (HFHS) implemented a mandate that required all high school field hockey players to wear protective eyewear in sanctioned competitions.93 This rule change resulted in a 69% reduction in the number of eye injuries but did not affect the rate of concussion [IRR=0.77 (95%CI:0.58-1.02)]89 One suggested strategy to reduce head injuries in field hockey is the removal of the penalty corner. In an editorial by John Batten, it is argued that penalty corners hold the potential risk of serious head injury and it is suggested that, instead, infringements within the defensive area be penalized by power plays. This is a system currently used by International Super Series Hockey.94

2.3.7 Gymnastics

Gymnastics is a sport where each individual element presents its own unique risk. However, these details are not typically captured in concussion surveillance data and the majority of evidence focuses on female athletes. While strains and sprains represent the majority of injuries seen in gymnastics, the concussion incidence rate is reportedly between 0.07-0.08 per 1000 AE among high school athletes8,95 and 0.16-0.27 among collegiate athletes.41,46 Concussions are more likely to occur in competitions than in practice. Marar et al.8 reported that concussions occurred 8.5 times more often in competition than in practice. Common mechanisms resulting in concussion in women’s gymnastics are surface contact during floor routine or uneven bars and contact with the balance beam.46 Therefore it is recommended that a coach monitor and spot athletes during these activities, especially when learning new routines. A study including 96 female gymnasts

16 from competitive levels 4 to 10 (ages 7-17) reported a lifetime occurrence of concussion of 30.2%.96 While concussion prevention strategies have not been evaluated in gymnastics, recommended injury prevention strategies include making sure that the equipment is in good condition (e.g. padded floors, secured mats under apparatus), using a safety harness for learning difficult moves and insisting on spotters when learning a new routine.

2.3.8 Ice Hockey

The sport of ice hockey is one of the most popular sports in the world and continues to grow in popularity globally.97 Canada leads the world in registration numbers with over 550,000 male and 87,000 female players.98 The next largest country in participation is the United States with over 530,000 total players.99 Historically, ice hockey has had the highest concussion incidence rate in male high school team sports,100 although a recent study found it was second only to American football.8 Regardless, concussion is the most common specific injury type for youth ice hockey players.11,100 Concussion accounts for 25-66% of all injuries in Pee Wee (11-12 years old) players playing with body checking, and 25-57% in a league not allowing body checking.6,10,11 Additionally, an American study found that concussions accounted for 22.2% of total injuries, the greatest proportion among 20 high school sports.8 Risk of concussion was identified as being consistently higher in games than practices,101 with one study finding concussions were 13 times more likely to occur during game play.8 In a recent systematic review which included a meta-analysis, body checking was identified as a consistent risk factor for all game-related injuries (summary rate ratio: 2.45; 95% CI 1.7-3.6) and concussion (summary odds ratio: 1.71; 95% CI 1.2- 2.44).101 Additionally, those with a history of concussion are at an increased risk of incurring a future concussion.6,9–11,101 Players that are lighter in body weight may also be at an increased risk of injury.10 Other risk factors for injury in youth may also exist such as age, level of play, and player position, yet the research remains inconclusive.101 With body checking being the single most consistent risk factor for injury in ice hockey, policy implications regarding delaying body checking to older age groups and only allowing body checking in the most elite levels of play should be considered.5,10,102

17 Other strategies for the prevention of injury in ice hockey include proper rule enforcement, and education of players concerning the risk of injury related to rule violation,70 as well as educating the proper techniques to give and receive legal body checks.

2.3.9 Lacrosse

Over the 2014-15 season there were 13,165 male and 10,994 female collegiate lacrosse players participating in the National Collegiate Athletics Association (NCAA) 64 as well as 193,235 (male: 108,450, female: 84,785) high school lacrosse players. 65 Concussion has been identified as one of top three game injuries at the collegiate level. 103 Concussion incidence rates for games and practices combined range between 0.26- 0.54 and 0.25-0.52 concussions per 1000AE among collegiate males and females respectively and concussions make up between 4.6 and 9.8% of all injuries. While high school lacrosse players have reported slightly lower rates of concussion than collegiate athletes, concussions represent a higher proportion of injuries seen in high school lacrosse. 8,47,104 In a study investigating high school lacrosse injuries in the United States between 2008 and 2010, concussions represented between 17% and 21% of the injuries sustained among boys and girls respectively.8 Between 1998 and 2008 the rate of concussion among high school lacrosse has been increasing annually by an average of 17% and 14% for boys and girls, respectively.47 In a study examining 51 and 55 sport related concussions in men and women collegiate lacrosse, players reported on average 5.12 and 5.69 symptoms following concussion.91 In men’s lacrosse, the most common mechanisms of concussion are player contact during general play and when chasing a loose ball. 46,104 In a study exploring lacrosse injuries from 1988-2004 nearly 80% of concussion injuries were due to contact with another player,105 while in women’s lacrosse the most common mechanism is when a player is defending either through player contact or stick contact. 46,104 There are differences between the rules in the men’s and women’s lacrosse game specially surrounding equipment and contact. The men’s game is a high-speed, contact game that has mandatory hard shell helmets, facemasks, mouth guards, gloves and padding for the upper body.104 Aggressive stick checking and body checking are legal

18 strategies.103 While the women’s game only allows incidental contact and women were only required to wear mouth guards up until 2005 when US lacrosse also made protective eyewear mandatory. The introduction of helmets in women’s lacrosse is controversial. Hard shell helmets are not permitted and while some players choose to wear soft protective headgear, US lacrosse has not made it mandatory. 103

2.3.10 Mixed Martial Arts

Mixed martial arts (MMA) has seen a surge in popularity in both North America and internationally,106,107 and in some areas has become more popular than boxing. Despite its popularity, MMA has been heavily criticized by many medical communities as being too violent and dangerous, and posing a significant risk of brain injury.108–111 However, the research examining the injuries sustained during MMA, particularly concussion, remains limited. One difficulty in determining the incidence of concussion in MMA is the classification of either a knockout (KO) or a technical knockout (TKO) as a concussion. The United Fighting League (UFC) defines a KO as occurring when a fighter is knocked down and either unconscious, disoriented, or unable to intelligently defend himself,112 and a TKO occurring when a referee stops a fight when a fighter is unable to defend themselves intelligently.112,113 In professional MMA the rate of knockouts range from 15.4-64 per 1000 athlete exposures.114–116 A systematic review and meta-analysis on injuries in MMA found the head was the most commonly injured anatomical region (66.8-78.0%), while concussion accounted for 3.8-20.4% of all injuries.117 Studies have found that the incidence of KO in professional MMA ranged from 15.4-64 per 1000 AE.114–116 Using video analysis techniques, one study identified that all KOs in their sample were due to impact with the head, and over 50% were due to a strike to the mandible.116 Hutchison et al (2014) found that 90% of TKOs were due to direct and repetitive strikes to the head leading to defenselessness of the fighter.116 Although diagnosis of concussion in cases of TKO was not certain, the combination of KO and TKO secondary to repetitive head strikes was 159 per 1000 AE and may suggest a more liberal estimate of the incidence of brain injury in MMA.116

19 The prevention of head injuries due to KO and TKO in MMA is difficult to be implemented in a sport that promotes and awards victory and financial bonuses for such match outcomes (e.g.; “knockout of the night” is a bonus awarded to the fighter with the most impressive KO/TKO).116 Although MMA fighters are required to wear gloves, one study found that a specific make of glove (safety-chop handwear) did not reduce the accelerations that may produce brain injury, and may actually protect the attackers hands more than the defenders head.118 Since fighters can sustain further strikes to the head after sustaining a KO and before the referee can intervene,116 Hutchison et al (2014) recommends policies and practices to reduce continuing head trauma after a KO. The authors propose a rule similar to boxing where a fighter is stopped for a count of 10 seconds after a knockdown to assess for identification of brain injury, which also eliminates further strikes after KO.116 Further recommendations include training of referees to better identify defenceless fighters and those that have lost consciousness and stop the fight immediately, and a uniform cross-jurisdictional injury database for all fighters to prevent premature return to sport after a brain injury.116

2.3.11 Rodeo

Participation rates in North American rodeo are difficult to ascertain as no comprehensive registry exists. One study obtained registration numbers from twelve rodeo associations including most of the largest rodeo associations in North America, and estimated that approximately 33,000 rodeo participants competed in 2009.119 The National High School Athletics Participation Survey reported approximately 135 men and 139 women participated in American high school rodeo over 2014-2015.65 There is a paucity of research that has investigated the incidence of concussion in rodeo. Only one study was identified that estimated the incidence rate of 3.4/1000 competition exposures.119 However, caution should be given to this estimate as the data were collected from 1995 through 1999, and may be an underestimate of more current rates. Historically, concussions accounted for between 11-13.9% of all injuries in bull riding and bareback riding, respectively.120,121 Although, more recent report found that concussions were the most common major injury and represented 55.8% of all major injuries during the 2001-2005 rodeo seasons.122

20 Of all the events in rodeo, bull riding has accounted for the majority of injuries representing approximately 50% of the total injuries in all events.122 Between 1996 and 2005 bull riders were more likely to sustain injuries to their head and face, usually due to colliding with the head or horns of the bull. 122 Although there is limited research that has investigated the use of protective head gear in bull riding, the authors and signatories of the Agreement Statement From the 1st International Rodeo Research and Clinical Care Conference agree that the risks of bull riding without head protection far outweigh the risks of bull riding with head protection.123

2.3.12 Rugby League

Rugby league is a code of football, which evolved from rugby union in the late 19th century as a professional sport for lower-class citizens and is a popular in Australia, New Zealand and England. As with rugby union, the tackle phase of play in rugby league has been identified as having the highest concussion risk124–127 and one study reported that concussions occurred in 40% of all illegal tackles.128 Until recently, the tackle laws in rugby league did not require the tackler to lead with the arms, but could instead lead with the shoulder, which is known as a “shoulder charge”. At the end of 2012, the Australian Rugby League Commission (ARLC) outlawed the shoulder charge, which was supported by the Rugby League International Federation (RLIF) and applied to all international competition from 2013 onwards.129 In New Zealand, the “shoulder charge” has been outlawed in domestic competition since 1995.130 Few studies have reported the incidence of concussion during rugby league training. No concussions were reported during a prospective study of training injuries to rugby league players from a professional club over the 2008 season.131 During the 2009 National Rugby League (NRL) season, concussion comprised 6.1% of all injuries during competitive matches, but only 1.4% of all training injuries. Concussion incidence rates in adult male rugby league have been found to vary with player position: 5.0-6.9 and 1.9- 30.7 concussions per 1000 player-hours for forwards and backs, respectively.132–135 In a comparison of limited and unlimited interchange rules, incidence rates of 5.1 and 3.0 concussions per 1000 player-hours were reported, respectively.136

2.3.13 Rugby Sevens

Rugby sevens is a variation of rugby union, in which seven players per side compete shorter game times with modified rules on a full-sized rugby field.137 Although developed in Scotland during the late 19th century, rugby sevens has only grown in popularity during the last few decades and several international competitions now exist, such as the World Rugby Sevens Series and Rugby World Cup Sevens. Rugby sevens has been contested at the Commonwealth Games since 1998 and had its debut as an Olympic sport in Rio 2016. As with rugby union, the tackle phase of play in rugby sevens has been identified as having the highest concussion risk, during which approximately 63-71% and 62% of all concussions are sustained for males138,139 and females,139 respectively. For both males and females, backs are more likely to sustain concussions compared to forwards and the incidence of concussion at the elite level is nearly three-fold that of the non-elite levels.139 Rugby league also has a sevens variant,140 for which a concussion incidence of 6.5 per 1000 player-hours has been reported for amateur and semi-professional male players.141

2.3.14 Rugby Union

Rugby union originated in England and was traditionally played throughout the United Kingdom, Ireland, Australia, New Zealand and South Africa. In 2015, there were 7.73 million rugby union players from over 100 countries.142 For youth rugby union players, McIntosh et al.143–145 found that concussion incidence tended to increase with age. Concussions during competition matches have a significantly higher incidence than during training,146 which have been reported as 0.0- 0.1, 0.3 and 0.4 per 1000 player-hours for professional male,147–151 collegiate male and collegiate female players,152 respectively. Some studies have investigated concussion incidence for the different playing positions of professional male rugby union players: 2.0-8.8 and 2.1-6.7 concussions per 1000 player-hours for forwards and backs, respectively.138,147,150,151,153

22 The tackle phase of play in rugby union has been identified as having the highest concussion risk,154,155 during which between half and two-thirds of all concussions are sustained to the tackler, ball-carrier and/or support players.138,147,156,157 The rugby tackle must be carried out below shoulder level with the arms wrapping around the ball-carrier player. This technique removes the danger of leading with the shoulder; however, it requires the head to be located close to the hips, thighs and knees of the ball-carrier, all of which have the potential to cause head injury. World Rugby allows soft-shelled padded headgear to be worn during rugby union matches;158 however, laboratory and field studies have demonstrated that commercially available headgear is ineffective in reducing the risk of concussion.159

2.3.15 Soccer

Soccer, which is also known as football or association football, is commonly referred to as the ‘world’s game’ as it is the most popular sport in the world with 265 million players.160 During open play, opposing players may come into contact with each other whilst competing for the ball; however, the objective is to play the ball and intentional collisions are not allowed. Concussion in soccer is most commonly caused by player-to-player contact,161–163 with the highest concussion risk event being identified as the aerial challenge.53,163–166 An aerial challenge occurs when two opposing team members jump into the air and both attempt to play the ball with their heads. Head-to-head contact and being struck by the upper extremity of an opponent are reportedly responsible for most concussions sustained during aerial challenges,163,167 with head-to-head having the highest risk of concussion.168 Elbow-to-head contact is another common cause of head injuries and concussion in soccer.161,163,167 It is generally accepted that there is not enough force in a single heading impact to cause concussion.161,167,169,170 However, the effects of cumulative minor head impacts from heading is uncertain,165,166,170–175 with retrospective studies suggesting an association between heading and cognitive impairment,176–181 but prospective studies finding no association between heading and cognitive impairment in both youth162,182–185

23 and adult186–193 players. Concussions from ball-to-head impacts, where the ball comes off a players boot and strikes the head of another player, have been reported.161,163,167 Interestingly, several studies have consistently reported higher concussion incidence rates for females then males in soccer.41,46,66,194,195 However, some people have argued this could be due to differences in concussion symptom reporting affecting identification. 196

2.3.16 Softball

Relative to baseball, there is slightly less participation in softball in American with approximately 1,500 high school men, 374,000 high school women, and 19,600 collegiate women who played either fast or slow pitch during the 2014-2015 season.64,65 Although softball and baseball have different rules and equipment, the sports have similar methods of play. At both the high school and collegiate level, softball had a higher rate of concussion than baseball.8,41,47,66,68 In addition to the differing rates, the mechanism of concussion also seems to differ with a greater proportion of amateur baseball players’ concussions caused by being hit by the pitch than softball players.8,66 Suggestions to prevent catastrophic injury in baseball, which may also be applicable to softball and aid in the prevention of concussions, include: making batting helmet use mandatory for both practice and game situations with proper helmet fitting, the use of protective screens during batting practice, teaching strategies to avoid contact when multiple players are chasing a fly ball, and teaching the proper skills and technique for head first slide.70 Major League Baseball has also introduced rules to reduce the number of injuries caused by collisions at home plate.197

2.3.17 Volleyball

Approximately 500,000 men and 5.5 million women play volleyball in high school and 15,000 men and two 200,000 women play volleyball at a university level. 198 While, volleyball is typically considered a non-contact sport with a limited risk of concussion, concussions do still occur. In women’s high school volleyball, the concussion rate reportedly ranges between 0.05 and 0.17 concussions per 1000 AE. 77,199 At the collegiate level the rate is higher ranging from 0.2 to 0.36 concussions per 1000AE.46,199 The majority of studies have not reported concussions in male volleyball

24 because of low numbers. Concussions are most likely to occur during defensive digging and common mechanisms include ball contact, surface contact, then player contact.8,46 In a high school sample, concussion in boys’ volleyball was primarily a result of player-to- player contact. 8 While in females, player-playing surface contact, and player-ball contact resulted in a greater proportion of concussions. 8 The risk associated with position was reported by Marar et al.8 where the outside hitter and setter position sustained over half of the concussions in a high school sample.

2.3.18 Wrestling

Wrestling is one of the top 10 (ranked 6) most popular sports programs for boys in the National Federation of State High School Association.65 While the popularity of wrestling among female athletes has increased since its introduction in the 2004 Olympics, available data on female wrestlers are limited. Wrestling is a sport that dictates absolute respect for one’s opponent and while wrestlers are supposed to be in control at all times during throwing and takedowns, concussions and other injuries do occur. Concussion represents between 3-10% of all injuries in wrestling with an incidence rate between 0.15-0.57 per 1000 AE among high school wrestlers and 0.25-1.09 per 1000AE among collegiate wrestlers.8,41,46,47,66,68,75,77,200 Concussions are most likely to occur during competition and the most common activities leading to concussions were takedowns (42.6%) and sparring (21.9%) in a sample of high school students.8

25 2.4 Key risk factors – how do I identify athletes at risk?

Identifying risk factors is important to help understand which athletes are more likely to be injured and what prevention strategies can be implemented to reduce risk. Risk factors can be broadly categorized as intrinsic (factors that are internal to the athlete) and extrinsic (factors that are outside of the body). While all risk factors provide valuable information, modifiable risk factors (factors you can change) provide the greatest opportunity for injury prevention. Currently there is very limited evidence on many of the proposed risk factors and the data are conflicting. However, being aware how position, level, specific mechanisms, weather, weight, fitness or pre-season symptoms may affect risk, may assist with the identification or prevention of concussion. While the previous section describes sport-specific risk factors, Table 2.2 describes the evidence of purported risk factors. The only risk factors with strong evidence are a previous history of concussion, playing in a game versus a practice and exposure to contact (body checking).

26 Table 2.2 Intrinsic and extrinsic risk factors for concussion in different sports Table 2 2.2 Intrinsic and extrinsic risk factors for concussion in different sports

Risk factor Relative Evidence Comments risk1 Intrinsic risk factors History of concussion 201 Increased risk with 1.65-6.60x ++ Studies examined ice hockey, football, soccer, rugby union and NCAA previous concussions athletes. Only three out of thirteen studies identified202–204 found previous concussion had no effect on risk and the studies were of moderate to low quality. Age 201 Younger cohort 1.21-1.89x +- Studies that found increased risk for younger cohorts compared: high school increased risk vs. college football players, middle vs. high school taekwondo athletes and youth ice skaters less than 6 years vs. greater than six years old. Included high to moderate quality studies. Older cohort increased 1.52-4.01x Studies that found increased risk for older cohort examined collegiate vs. risk high school, football 12-17 vs. 6-11, youth soccer players 15-18 vs. <15 years, cheerleaders collegiate vs. younger, ice hockey players, rugby players adult vs. high school, lacrosse players, and youth athletes (10-14 & 15-18 vs. 5-10 years). Three studies out of the 14 studies in youth ice hockey, rugby and lacrosse found no effect of age on risk. Sex 201 Male at increase risk 1.61-2.99x +- Studies that found an increase risk in males (4/23) examined: high school lacrosse, alpine sports, youth football, junior high athletics. Studies were primarily moderate quality with one high quality study. Studies that found females were at increased risk (10/23) examined: high school soccer, basketball, softball and baseball players, high school athletes, professional Female at increased 1.5-3.00x basketball players, collegiate athletes, adolescent soccer players, collegiate risks soccer players and wheelchair baseball players. Nine of the 23 studies found no effect of sex on risk among taekwondo, rugby, soccer, high school and lacrosse athletes. Genetics 201 Increased risk with TT 2.70x +- One of the 3 studies identified found an increased risk of concussion with APOE genotype football and soccer players that had the TT APOE genotype and concussion history. The remaining studies in collegiate athletes found no effect of having the APOE E4 allele or rare APOE allele. Neck strength 205 Increase risk with NA +- A study including 6704 soccer, basketball, and lacrosse high school athletes weaker neck strength found that for every pound increase in neck strength the odds of concussion decreased 5%. Playing position6,201 Inconsistent risk NA +- Six studies identified no effect of playing position in football, hockey and differences between rugby. Whereas, 2 studies have found being a goalie to be protective in positions hockey and one study found that quarterbacks are at an increased risk in football when compared to other positions. Level of play 201 Increase risk with lower 1.4-2.3x +- Of the 6 studies identified in football, ice hockey and rugby league, 2 studies division levels found that lower playing level is associated with increased risk and 4 studies found no effect of level of play on risk. Baseline Symptoms206 Increased risk associated +- In a study including 175 concussions in youth ice hockey symptom reporting with preseason reports was associated with a 1.47x increase of concussion risk for headache, 1.67x of headache, neck pain increase with neck pain and a 3.11x increased risk of dizziness. or dizziness Weight or BMI 201 Increased risk with low NA +- Two studies identified, one in rugby and one in ice hockey players reported weight or low BMI that lower 25% weight and lower BMI is associated with an increased risk of concussion But both were moderate quality studies. Fitness level 201 Increased risk with less +- Two studies were identified. One study in community ruby players reported training a hazard ratio of 1.48 associated with less training. While the other study reported no effect on risk in high school football players.

27 Risk factor Relative Evidence Comments risk1 Extrinsic risk factors Game vs. Practice 201 Increased risk with 2-205x ++ The risk of concussion was identified as greater in games than practices in games all 30 studies identified and across sports. Environment 201 Grass vs Artificial turf NA +- Three studies were identified in soccer. Two studies found no significant difference between the two surfaces and one study found a slight reduction in concussion risk on artificial turf. Match Period 201 Mixed results about NA +- Two studies were identified. One study found a greater risk of concussion in when players are more the 2nd vs. 3rd period of hockey. While the other study found no differences at risk in the 1st vs. 2nd half in rugby Body Checking 6,10,207,208 Increased risk with body 2.83-3.88x ++ Body checking has been identified as a significant risk factor for concussion checking leagues in youth ice hockey. Body checking experience has not been identified as protective. 1Relative risk indicates the increased risk of injury to an individual with this risk factor relative to an individual who does not have this characteristic. A relative risk of 1.2x means that the risk of injury is 20% higher for an individual with this characteristic. NA: Not available. 2Evidence indicates the level of scientific evidence for this factor being a risk factor for concussion ++ - convincing evidence from high-quality studies with consistent results; +- evidence from lesser quality studies or mixed results; 0 - expert opinion or hypothesis without scientific evidence

2.5 Sport-concussion Prevention: What can be done to prevent concussions? Preventing concussions can be understood across the full spectrum of care. This spectrum consists of primary prevention (preventing the initial occurrence), secondary prevention (early detection) and tertiary prevention (full recovery and prevention of second occurrence). Primary prevention of concussions is challenging because the evidence to support purported prevention strategies has methodological limitations or is still theoretical. These commonly promoted strategies include properly fitting equipment (e.g., helmets, mouthguards, headgear), rules and rule enforcement, improving coaching techniques, contact restriction, improving neck strength, and promoting respect and fair play.10,27–30 Table 2.3 presents a summary of some of the proposed prevention strategies that are often discussed.

28 Table 2.3 Summary of proposed prevention strategies Table 3 2.3 Summary of proposed prevention strategies

Primary Prevention Secondary Prevention Tertiary Prevention (Preventing the initial occurrence) (Early detection) (Full recovery and prevention of second occurrence) Helmets Education Vestibular Rehabilitation Headgear Policies Ocular Rehabilitation Mouthguards Return to Play Protocols Rule Changes Technique Education Contact Restriction Neck Strengthening Nutrition Encouraging Safe Play Vision training

2.5.1 Does protective equipment work?

Typically, sport governing bodies have rules and regulations outlining the use of protective equipment including helmets, headgear and mouthguards. While helmets protect against catastrophic focal head injuries, headgear can reduce superficial facial wounds209–211, and mouthguards protect against oral injuries81,212–214, this equipment is not completely effective at preventing concussions from occurring.27,215 Studies examining helmet fit, design, and age have reported a reduction of concussion symptoms and symptom duration associated with appropriate helmet fit216, a reduction of concussion risk associated with a helmet that has thicker padding over the zygoma and mandible (Riddell Revolution Helmet) when compared to other helmets217,218, and no difference between helmets that are different ages.219 Adding either full or half face shields to a helmet has not been shown to affect concussion risk.220,221 Biomechanical studies suggest that helmets may reduce forces applied to the brain, but there is no laboratory test or current standards that evaluate a helmet’s capability to prevent a concussion from occurring because the force needed to sustain a concussion is still not well defined.27,222 Evidence that examines the effectiveness of headgear in the prevention of concussion is inconsistent. Randomized controlled trials in rugby have found no protective effect.223,224 Whereas, some prospective studies and cross-sectional studies in soccer and rugby have found a 43-62% reduction in risk.147,225,226 The argument against the use of headgear in sport is that wearing it encourages athletes to take more risks and

29 increases aggressive play. In a survey of 122 male rugby players, 42.2% reported that they would be more aggressive during running or tackling if they were wearing headgear.227 However, this did not translate to an increased risk of concussion in the randomized controlled trials.223,224 There are three types of mouthguards: (1) custom-fabricated made by dental professionals; (2) form-fitted, boil and bite made by athlete biting the mouthguard; and (3) stock, bought directly over the counter.228 The goal of a mouthguard is to dissipate the force between the upper and lower teeth and act as a shock absorber.228,229 This can assist with reducing forces to the head with blows to the jaw. The evidence on the effectiveness of mouthguards in preventing concussion is inconclusive. There is some evidence to suggest that custom-fit mouthguards may offer an advantage over other mouthguards.230,231 But, currently studies are limited by small sample size, improper selection of comparison group, are produced by mouthguard manufacturers (potential conflict of interest) and poor identification of concussion. The potential of mouthguards to reduce the risks of concussions that result from blows to the jaw, and the proven effectiveness to reduce dental injuries in contact sports supports the use of mouthguards as an injury prevention strategy but further research is needed.

2.5.2 Rule changes and rule enforcement

Changing the rules in sport can be a challenging but effective means of reducing concussion. The key to an effective rule change is monitoring what mechanisms or environmental factors place an athlete at risk and then what rules can be put in place or mechanisms eliminated to reduce that risk. A recent example of an effective rule change is Hockey Canada’s decision to delay body checking until Bantam (ages 13-14). Multiple surveillance studies using both community surveillance and emergency room data identified body checking as a consistent risk factor for injury and concussion in youth ice hockey.6,10,11,207,232 Studies comparing provinces where body checking was allowed at the Pee Wee (ages 11-12) level to provinces where it was not permitted reported a 2.8 to 4- fold increased risk of concussion associated with playing Pee Wee in a body checking league.6,10 Furthermore, not having experience body checking at the Pee Wee level did not significantly increase a players injury risk in Bantam when they were allowed to body

30 check.9 The removal of body checking at the Pee Wee level resulted in a 64% reduction of concussions when the same city was compared before and after the change.37 233 Stricter enforcement of rules that sanction players for head contact have yielded mixed results when it comes to concussion prevention. In 2010, the Football Association of Norway and Norwegian Professional League Association decided to implement stricter rule enforcement by referees. 234 The changes included giving an automatic red card for two-foot tackles, tackles with excessive force and intentional high elbows.234 Comprehensive referee training and a media release to the public that explicitly outlined the changes accompanied the rule enforcement decision. When they compared video of soccer games the year after the rule enforcement was implemented to games a year before the changes, they found a 19% reduction in the number of hits to the head. The reduction in exposure to head contact could possibly reduce concussions over time. However, the study was limited by a low number of concussion incidents. On the other hand, when Hockey Canada decided to implement a zero tolerance for head contact rule where players would be penalized by referees for any contact to the head, it did not decrease concussion risk or head contacts.235 While it is possible the lack of protective effect might have been due to the increasing rates of concussion across all sports when the historical cohort study took place, it may also be that referee enforcement was not enough to modify the hockey players behaviours, or the enforcement was not consistent. Understanding how to implement a rule change that will be effective at reducing concussions in sport begins with understanding the mechanisms of concussion for that sport. The rule change should aim to eliminate or reduce exposure to that mechanism. Implementation should include the organisation, referees, parents, coaches and players.

2.5.3 Coaching, neck strength, training, nutrition, and encouraging safe behaviours

Coaching strategies, vision training, neck strengthening, nutrition, encouraging safe behaviour and education campaigns promoting certain techniques (ex. Respect on ice and USA Hockey’s, “Heads up don’t duck”)236 have been postulated as injury prevention strategies. However, the evidence in support of these strategies is sparse, inconsistent or non-existent at this time.27

31 Coach education about proper tackling techniques, equipment fitting, and strategies to reduce contact in football combined with limiting contact in practice show promise as a prevention strategy.55,237,238 When concussion rates were compared between teams with coaches who were both exposed to the Head’s Up Football program education and restricted contact in practice to teams who did not do the program or contact restriction, a 82% reduction of concussion in practice was reported.238 Another study compared football players exposed to 5 minutes of tackling training without helmets during practice to players who did not get the training and found a reduction in game head impact frequency for the players exposed.55 Limiting contact in practice and teaching appropriate techniques for collisions are strategies that can be used in many contact sports. While the results of these three studies of coaching strategies are promising, more research is needed. Overall neck strength has been identified as a predictor of concussion, with one study reporting that within a high school sample for every one-pound increase in neck strength, the odds of concussion decrease by five percent.205 This has led many to suggest that if you strengthen the neck, you can reduce your risk of concussion. While training cervical musculature has been associated with increases in neck strength, no evidence has examined the effects of a neck strengthening program on concussion risk.27 One new strategy that has been proposed to reduce the rate of concussion is vision training. As part of the University of Cincinnati football program, the team conducted vision enhancement training during the preseason using Nike strobe glasses and tracking drills. Clark et al. 239 monitored concussion incidence over four seasons of training and compared the incidence rate to the rate over the previous four seasons. The study found a significant reduction in concussion incidence. However, further research is needed to see if these results are consistent across different teams, or sports. The possibility of nutritional interventions as a strategy for concussion prevention is still in its infancy. Omega-3 Fatty acids, curcumin, resvestrol, melatonin, creatine, Vitamins C, D and E and S. baicalensis are purported interventions for concussion prevention and management, but most have not been tested in human trials.240 High dose docosahexanoic acid (DHA) supplementation has been shown to reduce markers of axonal damage in varsity football players241 and reduce the damage inflicted to traumatic

32 brain injury mouse models,242 but whether DHA has the ability to prevent concussions is still not clear. Encouraging safe behaviours and respect is a commonly promoted strategy for injury prevention that can be used across all sports. Fair-Play rules reward teams for not committing fouls or disrespecting other athletes. While endorsed by some recreational leagues, the effect of fair-play programs on injury has only been examined in one study that found a reduction in overall injuries but, was unable to detect a difference in concussion specifically due to a limited sample size.243 There is evidence however to suggest it can affect player behaviour. A Hockey Education Program in Minnesota, with Fair Play, reduced potentially dangerous infractions by 30% when compared to standard practice rules.28,244

2.5.4 Secondary Prevention: Policy and Concussion Education

Trainers, parents, players, and coaches all play a role in identifying and ensuring proper management of concussion.18,31,32 Poor symptom recognition or lack of concussion awareness can contribute to unrecognized concussions that increase the risk of continuing to play with a concussion and prolong recovery or make the injury worse. Policy on concussion management and education has been proposed as a method for increasing appropriate concussion management. In 2009, Washington State adopted legislation (the Lystedt Law) that outlined how concussion should be managed and promoted education for coaches, parents and players. Similar legislation was adopted across the United States. One evaluation of the implementation of concussion legislation reported that since adopting the legislation there have been increases in visits to the emergency department for concussions, which has been attributed to more individuals seeking care following concussion.245 While raising awareness through education and policy is important to assisting with identification of concussion, the beliefs of parents, players and coaches can affect whether or not they choose to respond appropriately.33 These beliefs can include, but are not limited to, the perception of risks of negative outcomes associated with a given behavioural response (e.g. player reporting symptoms), expectation of what will happen if they perform the desired behaviour and perceived confidence in their ability to perform

33 the behaviour.34 Education that is not theory-based and does not consider how to address the beliefs that underlie player behaviour may lead to the opposite of intended effects. For example, a study of adolescent male Junior ice hockey players found that providing publically available concussion education that is designed to increase awareness but not address beliefs that underlie behaviour can actually decrease players’ intentions to report their symptoms to an adult.246 This lack of reporting can contribute to undiagnosed concussions. On the other hand, when a group of coaches received access to a theory- driven course designed to address the beliefs that underlie behaviour, the intervention group demonstrated a greater increase in behavioural intention to remove an athlete than the group of coach who just received safety information to read.247 When deciding how to use education or legislation to assist with concussion secondary prevention or primary prevention, it is essential to first understand the beliefs and motivations of the population you are educating.

2.5.5 Tertiary Prevention: Return to sport and prevention of second occurrence

Safe return to play protocols, vestibular rehabilitation, and ocular rehabilitation have all been identified as methods to assist with return to sport and reducing the risk of a second occurrence. These topics are outside of the scope of this Chapter.

2.6 Conclusion Concussions have become a major health problem in sport. While concussion can occur in any sport, the incidence is highest in collision and/or contact sports including American football, Australian football league, ice hockey, rugby, lacrosse, soccer and wrestling. Sport characteristics, games when compared to practices, and a previous history of concussion are consistent risk factors. Finally, while primary prevention is difficult, identifying the mechanisms of injury and potential rule modification that can limit exposure to that mechanism have been identified as successful concussion risk reduction strategies.

Chapter 3: The complexity of concussion management in youth ice hockey: A qualitative study

35 3.1 Background Sport and physical activity are strongly recommended for their benefits toward child development and general health; however, the risk of injury has some parents questioning their decision to enrol their children in sports.3,4,248 Driving some of these concerns is the increased media attention around the dangers and long-term consequences of concussion.249 Each year, approximately 1.1 to 1.9 million children and adolescents under the age of 18 suffer a sport-related concussion.250 A concussion is a type of brain injury that occurs due to biomechanical forces applied either directly or indirectly to the head. The injury typically results in transient signs and symptoms and largely reflects changes in brain function rather than gross structural changes.21 When managed appropriately, the majority of children can recover without rehabilitative intervention within two weeks to one month.91,251,252 In cases where the child continues to participate in sport – such as when the injury goes undetected or is mismanaged - there is a higher risk of consequences that can include prolonged recovery, long-term disability and in rare cases, even death.17,35,36 In order to mitigate the risk of secondary consequences due to playing through a suspected concussion, it is recommended that the player should be removed from play, evaluated by a physician or healthcare provider, rest, undergo rehabilitation if necessary, recover from post-concussion symptoms, and then undergo a graduated return to sport protocol.21 While this step-by-step recommendation seems straightforward, the implementation can be much more challenging. In youth sport many teams do not have access to a trained healthcare provider to assist with sideline management. Therefore, the responsibility for initiating appropriate concussion management is often placed on players, parents and coaches. In these cases, appropriate management involves recognition of the signs and symptoms of concussion (player and coach), removing the player from the game (coach), medical follow-up (parent) and a stepwise return to play including medical clearance (parent, player and/or coach with guidance from a physician).21 Previous research has focused on the barriers and facilitators surrounding a player’s willingness to report concussion symptoms.253 While symptom reporting is key to identification, it is only one step toward concussion management. Understanding the motivators that predict parent and coach concussion management is also essential to

36 inform a comprehensive educational program that can change concussion management behaviours and reduce the risk of secondary complications. Using youth ice hockey as a case example, this paper aims to explore the parent and coach experience with concussion management. A key focus is placed on participant understanding of concussion signs and symptoms and comfort surrounding management while highlighting potential barriers and facilitators to a coach removing a player from play due to a suspected concussion as well as parent taking their child to see a physician. Implications for future concussion education interventions are discussed.

3.2 Methods

3.2.1 Participants and Recruitment This study includes a total of 24 parents and coaches who participated in semi- structured interviews from July-November 2015. The first 8 participants were recruited using purposive sampling based on participant type (e.g., mother, father, coaching experience), level of hockey (i.e., elite and non-elite) and high or low concussion knowledge based on a previous year’s assessment. The remaining participants were recruited based on availability during baseline testing sessions for a 2015-2016 prospective cohort study examining body checking rule changes in hockey. Recruitment continued until data saturation (i.e., no new themes emerged). The final sample included nine male parent coaches, five fathers without coaching experience, seven mothers and three male coaches who were not parents. All parents interviewed had at least one son in the study playing Pee Wee (11-12) or Bantam (13-14) ice hockey. All coaches were affiliated with a male team at the Bantam level.

3.2.2 Data Collection Interviews took place at the University of Calgary campus in either a research office or boardroom. The interviewer and first author (AB) is a Certified Athletic Therapist with experience managing concussions both in the clinic and on the sidelines at games. AB has worked for collegiate ice hockey teams, played hockey as a child and has a history of multiple concussions. Therefore, she is in an ideal position to understand hockey terminology, hockey culture, and concussion as an injury. The interviewer’s

37 clinical training and sport background were neither explicitly mentioned nor hidden during the interview process. Field notes were taken at the end of each interview indicating key messages that emerged as well as relevant observations. Notes were only made during the session if there was significant disruption to the interview that may have affected the quality of the transcription. This allowed for an engaging discussion between the participant and the researcher. Interviews were digitally-recorded, transcribed by a professional service, and then reviewed for accuracy. A semi-structured interview guide with standard preamble was used to cover four topics: 1. Participant experience, understanding, beliefs and previous behaviour related to concussion prevention and management in youth ice hockey; 2. Concussion education experience, needs and strategies; 3. Exposure to the Concussion Awareness Training Tool (an educational intervention), and; 4. The effect of being in a concussion study. Interviews lasted between forty minutes and ninety minutes. (See Appendix B for interview guide)

3.2.3 Qualitative Data Analysis Data were analyzed using the thematic analysis approach outlined by Braun and Clark.254 Familiarization with the data occurred during data collection and throughout data analysis. Field memos were made by the interviewer after the completion of each interview and while reviewing the transcripts. The memos included reflections on the interview process, impressions of the participant, and key themes that emerged from that interview. Transcripts were read a minimum of two times and reviewed while listening to the recording. Initial codes were derived deductively based on topics covered by the interview guide, known constructs from behaviour change frameworks (i.e., risk perception, outcome expectancies, self-efficacy, action planning) and inductively based on key themes that related to the research aims. Two researchers AB and OO reviewed the first seven interviews and discussed initial codes and themes. The remaining interviews were coded by AB and discussed with members of the research team. Initial codes, field notes and memos were collated and organized using NVivo for mac version 11. Nodes related to participant experience and understanding were explored for the purpose of this analysis. Themes were identified, defined, and reported as they related to the understanding of the experience of concussion management. The analysis focused on

38 participant experience, understanding, and behaviours related to removal of an athlete from play and seeking medical attention following a suspected concussion. Trustworthiness was addressed using peer debriefing and reflexive memoing.

3.3 Results There were differences in the way the concussion experience was described from the perspective of a coach managing a concussion of a player on their team relative to a parent describing their experience witnessing a suspected concussion of their child or another child on the team. Therefore the results related to concussion experience were separated and presented according to the role the participant was reflecting on while describing the experience.

3.3.1 Concussion experience in context: Parent While describing their personal experience witnessing a concussion or reacting to an event that presented a potential mechanism for concussion, three key themes emerged for parents: concussion as an emotional experience; feeling powerless; and trust. Appendix C provides a full list of quotes used to generate themes. Most parents described witnessing a concussion or a concussion-related incident as an emotional experience filled with fear, worry and nervousness. For example, a mother and a father explained: "Usually, you get an immediate jolt in your stomach and panic and ‘is that my kid?’. It’s the first things I go through my mind when I see something like that. Then I start thinking: ‘is he moving?, do I see any movement? Is he moving? Is he getting up, what’s going on? Who’s out there? Is he okay?’ I just start thinking about is he breathing, is he moving, is he? Is he okay? You hold your breath until you see them move and get up. Then you completely ignore the game, because then you’re watching the child." - Mother 6

"I guess at the time of the collision first you're in a state of, ‘Was that my kid?’ Then you confirm it's your kid, and you're like in a frozen kind of a state, you want that kid to get up or want your kid to start to as soon as possible become normal. There's a coach that runs out and crouches over that kid so the feelings there are just in complete

39 suspension. - Ultimately the kid gets up or is carried off and there's a clap and then depending on what happens next or how. Usually those hits to the board, they actually sound really bad sometimes and sometimes they're not really bad, they just shake the kid up, so you hope for that, I guess it is sort of a hopeful thing and a very fearful thing. " - Father 4

Some parents felt powerless to act on their desire to control the situation, whereas others put complete trust in themselves, the coaching staff, and/or the team medical personnel to manage the concussion. For example, this father described feeling powerless when he witnessed his son suffering an impact which ended up leading to a concussion: "I would have liked to crawl on the ice at the moment, but we just wanted to see if he was going to stay in the game or trying to figure out if he was going to come off." - Father 1

Whereas, this mother described putting complete faith in the coaching staff to care for her son: "At that point, I'm completely out of the loop. I trust all their coaches, and have, that if they are complaining of a headache or if they think that it's a really major ... it's a major situation to keep them out of the game, then I let them make that decision, and then I'll just wait and see what happens." - Mother 1

3.3.2 Concussion experience in context: Coach The coach experience with managing concussion is slightly different than the parent experience. While some coaches described an experience of emotional reactivity consisting primarily of concern or anger toward the player or team causing the injury event, others expressed the need to remain objective and focused. For example, in response to a scenario about a player getting concussed, this coach described a feeling of concern: "It’s terrible, worst thing. Definitely don’t feel good at all and certainly your first reaction is, ‘Oh jeez I hope he’s okay.’” – Parent Coach 6

40 On the other hand, some coaches believe that the experience needs to be objective and they need to remain calm. For example, in response to a question about how witnessing a concussion makes him feel, this parent coach explained: “I don't know. Indifferent is not the right word, it's somewhat removed. I don't get emotional about it. The most important thing is to make sure the kid is you know… I'm indifferent to the play that caused it to happen. I don't care whose fault it was at that point. Number one thing is to just make sure the kid's okay and don't… - take emotion out of the equation. You have to be very calm when you're going after a kid that's been rattled. You don't want to be hysterical in and of itself." - Parent Coach 1

Two additional themes emerged related to concussion management in a coaching role. The first concerns how the injury assessment can be complex, challenging, or difficult to judge, as explained by these two parent coaches:

“I think that minor concussions are a lot more difficult to determine. Sometimes you might not have a concussion but you've certainly given yourself a good rattling that is borderline onto a concussion and if you take another hit, pretty soon after I think that that's a challenge. " - Parent Coach 1

“It's a tough one because you want the kid to be able to keep playing the game especially if he doesn't look like he's overly hurt and everything is okay. On the other hand, you don't want to be the person responsible for letting that kid play when he actually has a concussion. I don't know. Is it you take every kid off the ice because of minor headache and that's been bumped in the head and you think they have a concussion? Is it when we have to see more serious signs before they get pulled off the ice? It's a really tough ... Really a judgement call at the end of the day and a judgement call is being made in most cases by a non-medical person, somebody who has a layman's knowledge of what a concussion looks like or feels like or anything like that." - Parent Coach 3

41 The other key theme describes how coaches can feel a burden of responsibility for the athlete’s safety. For example, one parent coach explained:

"We are the only people on the bench, we are trusted with that child’s safety and I would hate to be the person to overlook something. I think that’s fundamentally my job is to protect these little kids. They are all our little kids running out there. When something happens, that parent’s not there, it’s my job to make sure that the kid’s okay. I think the thought process I go through is making sure that I’m checking off my mental checklist in terms of what I need to look for, and again, protecting the kid from further damage. I don’t care what the parents are going to say, they weren’t there and I’m the adult." - Parent Coach 8

3.3.3 Understanding of concussion symptoms and management: Parents and coaches When asked about concussion signs and symptoms, all participants were able to identify a few signs and symptoms associated with concussion. The most common symptoms discussed by participants as causing concern were nausea or vomiting (n=17/24), headache (n=15/24), and dizziness (n=14/24). Participants’ confidence in their knowledge appeared to decrease when they had to apply the concussion symptoms in a management scenario. This was indicated by their use of words such as “I think”, “I guess” and “maybe” when describing management and/or return to play. This provided evidence for the theme: Knowledge does not equal understanding. For example, when asked what would need to happen before a hypothetical player with a suspected concussion returns to play, this parent responded: “Well, I don't know. I imagine I'd probably go back to the doctor, but he might not know. He might say, "It's been a week and how do you feel?" He'd probably ask him. Maybe if it was a bad one, a week or two. I don't know. I don't know when you know you're better” - Mother 2

3.3.4 Barriers and facilitators of appropriate management: Removal from play Based on participants’ descriptions of previous management of concussion or response to a concussion scenario, athletes with suspected concussions may not be removed from play for several reasons. Players downplaying their symptoms can be a

42 barrier to the coach identifying the incident as a concussion and removing a player with a suspected concussion from play. An additional challenge for coaches is the difficulty of performing an assessment while the game continues pulling their focus. Finally, there is also a lack of understanding that symptoms can be delayed or may not be severe initially. This often results in a tendency to use the sit a shift technique where the coach allows a player to play despite the initial indication that a concussion may have occurred and allowing the player to make the choice on whether they would like to go back to play. See Table 3.1 for barriers and facilitators along with associated quotes.

43 Table 3.1 Barriers and facilitators to an athlete with a suspected concussion being removed from play Table 4 3.1 Barriers and facilitators to an athlete with a suspected concussion being removed from play

Barriers Sample Quote Players concealing or "Sometimes players don't honestly tell you what's the matter. I think that downplaying the severity of minor concussions are a lot of more difficult to determine. Sometimes you their symptoms might not have a concussion but you've certainly given yourself a good rattling that is borderline onto a concussion and if you take another hit, pretty soon after I think that that's a challenge. You don't want anybody to get hurt and you want people to play a competitive physical game. I think those are some of the bigger challenges." - Parent Coach 1 Difficulty conducting an "Like if you look at him and he seems kind of out of it. Or if his headache assessment in suspected is so bad that he has to take Advil that's... Other than that I don't really cases when the game know like as a head coach I just send them to the assistant coach if it gets continues that bad. Because I have to keep coaching so. It is my call so at the end of the day but at the same time I don't make it unless I have too." - Coach 2 Lack of understanding that “This happened two weeks ago.” [in reference to asking about a scenario symptoms can be delayed or where a player took a bad hit to the boards and was complaining of a slight may not be that bad initially headache] We helped him off the ice, he complained his head hurt. We resulting in the “sit a shift made him sit down on the bench. Took off a couple of shifts. He looked at approach” to management us and said, “I’m fine. I’m not dizzy. I’m okay.” Then he went back out on the ice – Parent Coach 7

“We went out and he obviously felt ... Complained a little bit of a headache but it wasn't anything major. We brought him back to the bench. I had him sit out for a number of shifts, just had him sit there, looked at him, had some of the other coaches check him out as well, asked him about the headache, and then just continued to follow up with him for probably about 5 or 6 shifts, I would say and just asked about the headaches, see if it was worse, tried to look at his eyes to see if his pupils were dilated, and then asked him a couple of questions about if he knew where he was and what happened to him and all those kind of things. He’s able to answer them all and nothing really popped out besides a little bit of a headache feeling. The headache didn't get worse over the time while we were talking to him. At the end of about 5 or 6 shifts, we put him back on the ice and seemed to be okay and we never heard any follow up to anything that happened to him more serious than that” Parent Coach 3 Facilitators Strong belief in “when in "My role, primary rule above all else as a coach is to ensure the safety of doubt sit them out” or player kids. Then we go into everything else, the fun, the hockey, everything else safety regardless of when it and stuff but it has to be the safety so I have to air on the conscious side. If happens he comes back, if I A) have to pick him up and B) he goes "oh I got a headache" you know what, you're going to sit here for a while and we're going to figure this one out." - Parent Coach 9

44 3.3.5 Barriers and facilitators of appropriate management: Physician Assessment Interviews with parents and coaches suggest that whether or not physician follow- up occurs following a suspected concussion is related to the interaction between the coach and the parent and/or the parent’s interpretation of what happened and the severity of the sign or symptoms reported by the child. Table 3.2 provides a full list of specific barriers that can affect physician referral along with associated quotes. When the team does not have a protocol that mandates physician clearance, parents can challenge the coach’s or therapist’s recommendation to see a physician. This often occurs because of a parent’s perception of the severity and interpretation of symptoms reported by the child. For example, this mother explained that she did not take her child to a physician despite the team athletic therapist identifying the concussion because she didn’t believe the symptoms were due to a concussion: “My son was at a tournament just this weekend, and he's a goalie, and he got hit in the head with the puck and he wasn't feeling well after, throughout the day. Immediately it was called a concussion, but when I talked to him, I said, "How much have you had to drink today?" Well, he hadn't, so he was showing signs of dehydration, but it was misdiagnosed, so it worries me that I think concussions are something that have to be prevented and it's very important to diagnose them properly.” – Mother 5 Another barrier that some parents both experienced and perceived is physician access and availability. When the symptoms resolve prior to the availability of a physician a parent may choose to no longer go. The consequence is that they may not get the proper recommendations regarding a graduated return to play. (See Table 3.2 for quotes) Parents often perceive that when other parents do not take their child in to a physician, it is likely due to a lack of education or understanding. Several other barriers were identified as perceived barriers by participants but not evident in participants description of experience including: the importance of upcoming games, the parent feels they are wasting their money if their child does not play, parents are too busy, parents don’t want their child to have an injury record or they do not feel they will learn anything new.

Table 3.2: Barriers and facilitators to a parent taking their child for physician assessment and follow-up Table 5 3.2 Barriers and facilitators to a parent taking their child for physician assessment and follow-up

Barriers Sample Quote Lack of understanding "At the time he was injured, we weren't quite sure if it was really a... It was around the timing, almost like a twofold. It took him almost two practices like a first incident in importance and specificity a game and then he didn't really have a rest and then he had another game, of signs and symptoms back-to-back almost like days. He's a defenseman. I'm used to him getting hit. I keep an eye to make sure. I ask him how he's feeling so that I don't put him at risk of more injury. Honestly, it didn't concern me a whole lot. It wasn't a super bad incident at the time. Obviously, as his symptoms started to worsen and he was starting to mention that, ‘Yes. I do have headache. I don't feel well. I'm getting dizzy.’ That type of thing. Then I started to get more concern which was when I took him to his family doctor." - Mother 4

Physician access "I guess it has to be right because most games hockey at this level and this (Availability and timing) age happen on the weekends. You can’t get in to see a family doctors until it's Monday to Friday so you usually wait until the weekdays and then by then the symptoms have gone away most of the time they’ve gone away. If they’re still there then obviously you’re going to either go to your doctor or you’re going to get them into the emergency room. I think that plays a big part in it too because most hockey games happen on the weekend and you can’t get in to see your doctor until Monday or Tuesday and you’re even lucky if you can get them in at that point"- Parent Coach 2

Parents feel they know In response to: Do you think your doctor might be able to see some of the their child best things you wouldn't be able to see: "Possibly, they’re definitely trained in spotting stuff like that, but then again, as a parent, we know our kids better than anyone else. We know that what they’re doing is normal or not normal." - Mother 6 Lack of education is a “I think that the reason they don't want to see the doctor, basically, is lack of perceived barrier education. I think that they just don't realize what a concussion can do. ‘Yeah, my kid has a headache. Whatever. We'll get him back and he'll be playing hockey and he'll be fine,’ but I don't think they understand what it's doing inside their brains, and I think maybe if they're educated on that, that they might be more likely to, ‘Hey, you know, I got to get to the doctor.’ When the trainer says, ‘Do you have a headache?’ Make sure you say ‘yes.’ - Mother 4 Facilitators Team protocol enforces a “Stress to them that you need doctor clearance at the end of this. I think that doctor visit was the step I forgot to mention, but mention to them that you do need doctor clearance and like a signed letter form a doctor saying he's good to play type thing.” - Father 5

46 3.4 Discussion This study addresses key gaps in the literature regarding the parent and coach experience and the barriers and facilitators to concussion management in a Canadian youth sporting population. Some of the barriers to removal from play following a suspected concussion identified in this sample are consistent with barriers reported in a previous exploration of sport coaches using a closed-ended questionnaire. For example, Bramley et al.255 reported that while coaches may be unwilling to return a player with a severe concussion to play, there are some coaches who may consider returning a player with a minor concussion, a player who says they feel better, or regardless of the injury when it’s a championship game.255 Similarly, the barriers to seeking medical attention in this sample are consistent with a previous study examining parents’ motivations for following up with a physician after visiting an emergency department for a head injury. Bazarian et al256 reported that reasons for following up included: the parent thought it was important (51.6%), was told to do so by emergency department instructions (64.5%), the child still has symptoms (38.7%), and insurance paid for the follow-up visit (9.7%). Reasons for not following up were (n=12): did not think it was important (41.7%), was not told to do so (41.7%), and symptoms resolved (75%). Bazarian et al.’s closed-ended questionnaire design did not allow for an exploration of how the coach and parent experience interact in order to promote appropriate behaviour. This study highlights that parents often trust coaches decisions on what to do if their child has a concussion and in some cases a coach can facilitate physician management by appropriately communicating the necessity to the parent. Some of the participants suggested that having protocols (e.g., mandated removal from play and physician follow-up of players with suspected concussion) in place may facilitate appropriate concussion management. However, it is important to recognize that management can be challenging even when there is legislation in place and help from athletic therapists. As the athletic directors of Rhode Island School reported during an evaluation of the Youth Programs Concussions Act, parents sometimes try to overrule decisions about a suspected concussion made by certified athletic trainers.257 This was

47 also the experience described by a mother of a player on an elite team in this sample who had a trainer identify a concussion and yet did not take their child in to the physician for assessment and follow-up because the mother did not believe it was a concussion. This may highlight the need for protocols to be implemented alongside educational strategies aimed at changing the beliefs and awareness of concussion for parents. Finally, the theme identified surrounding the disconnect between knowledge and understanding provides some explanation as to why education that has been shown to improve a participant’s knowledge of signs and symptoms based on symptom recognition may not translate to a parent’s or coach’s confidence to be able to apply that knowledge independently in a management scenario.

3.4.1 Conclusions and recommendations for concussion education Concussion management in youth ice hockey is a complicated process that involves the player, parent, and coach working together to recognize that an injury has occurred, remove the player at risk from play, refer the player to a physician, and follow a graduated return to play protocol. Barriers to concussion management identified in this study relate to 1) players’ unwillingness to report symptoms, 2) coaches having difficulty identifying concussions, and 3) parents underestimating or misattributing symptoms. Our findings can inform the generation of specific interventions that can target these barriers. They also highlight the importance of team protocols in facilitating appropriate behaviour. Techniques that aim to increase confidence (self-efficacy) around concussion symptom assessment as well as provide coaches and parents with the tools they need to communicate with each other as well as with the players may assist with increasing the amount of concussions that are treated appropriately.258

Chapter 4: Does receiving information about concussion affect concussion management knowledge, beliefs and/or behaviours? Part 1: Youth ice hockey players

49 4.1 Introduction Sport-related concussion has become a major public health concern. In the United States alone, 1.1 to 1.9 million children and adolescents under the age of 18 are estimated to suffer a sport-related concussion each year.250 A concussion is a type of traumatic brain injury induced by biomechanical forces to the head or body.21 Appropriate sideline management of the injury requires both recognizing that a concussion has occurred and removing the athlete from play.21 Removal from play should be followed by medically guided evaluation, rest, recovery, rehabilitation if necessary, and stepwise return to play.21 The majority of first-time concussions resolve within a few weeks to a month.91,251,252 However, if a concussion is not recognized and/or a player chooses to play through their symptoms, the player can experience prolonged recovery, long-term problems and, in rare cases, death.17,35,36 In an effort to reduce the negative consequences due to mismanaged concussions, sporting organizations and government have turned to implementing laws and policies surrounding removal of an athlete from play, concussion management, and concussion education. As of 2014, all 50 states and the District of Columbia in the United States have implemented concussion legislation.259,260 While the details surrounding concussion state legislation may differ, most include three core tenets: 1) An athlete must be removed from play if a concussion is suspected, 2) Medically supervised concussion management is recommended, and 3) There should be concussion education.259,261 Evidence suggests that providing concussion education to athletes can increase knowledge about the injury.262 However, there is limited and conflicting evidence about whether education also affects attitudes/beliefs about concussion and/or player management behaviours.262 There is even more conflicting evidence about whether changes in knowledge, attitudes, practice and/or behaviour intention persist long- term.263,264 Player symptom reporting has garnered much focus in recent attempts to facilitate concussion management for youth sporting participants.262,265 Given the importance of symptoms in diagnosing concussions, players reporting their concussion symptoms to a coach, parent or athletic trainer can assist with concussion recognition and facilitate appropriate care.21 Yet, given the subjective nature of symptoms, players can choose not to report, or may not recognize a symptom is important enough to tell a coach,

50 parent or medical team. Previous research has examined many potential reasons for player non-disclosure: the player not thinking it was severe enough, not wanting to leave the game, not knowing it was a concussion, not wanting to let their team down, not wanting to be pulled from a future game, believing concussions are part of the game, and not wanting to let their coaches down.265 The majority of these reasons have been examined outside the context of a behaviour change framework, which limits the ability to customize and evaluate interventions that target salient motivators of behaviour. The majority of studies examining concussion education in athletes have been conducted in the United States with a focus on how education increases knowledge, without considering the motivators of behaviour change.266–268 Aside from one study by Glang et al247 in 2010, only in the last few years have investigators started to incorporate some principles of behaviour change into the design and evaluation of their concussion education interventions.269,270 These studies have attempted to examine concussion education within the context of the theory of planned behaviour or health belief model. The theory of planned behaviour can assist with evaluating the impact of concussion education on the motivators of intention to perform a specific behaviour; however intention does not always coincide with the execution of behaviour.271,272 The motivational phase/pre-intentional phase of the Health Action Process Approach (HAPA) is similar to the theory of planned behaviour, but also proposes planning and self-efficacy around maintaining behaviour in different circumstances as key mechanisms for addressing the intention to behaviour gap. Given potential differences in attitudes and beliefs in the United States relative to Canada and the limitations associated with the theory of planned behaviour, more research is needed. Currently in Canada, most provinces do not have any legislation surrounding mandatory concussion education. Individual school boards and sporting associations can choose whether or not they implement a concussion policy. To make recommendations regarding future changes to concussion education policies, it is important to understand the effect of providing concussion education on both knowledge of concussion and the beliefs and behaviours related to concussion management behaviour. This issue is especially important in Canadian youth ice hockey, where there are high participation rates nationally and one of the highest rates of concussion in team sports.1,12 Therefore,

51 the primary objective of this paper is to determine the association between self-reported exposure to concussion education in the last year and knowledge, beliefs and self- reported management behaviour among youth ice hockey players (ages 11-17) under the scope of the Health Action Process Approach.273 A secondary objective is to describe where hockey players receive information, how helpful they find the information provided, and who they would like to receive further concussion education from. Given that most of the available education on concussion has been designed with the goal of knowledge translation and not designed with the tenets of behaviour change theory in mind, the authors hypothesized that a player receiving concussion education in the last year may have increased knowledge about concussion, but may not display differences in beliefs or behaviours related to reporting.

4.2 Methods

4.2.1 Sample and Procedure Participants were identified from a sample of 1847 players (ages 11-17) from hockey associations in Calgary, Edmonton and Vancouver, participating in two prospective cohort studies designed to assess the risk of concussion and injury in youth ice hockey during the 2015-16 ice hockey season. Beginning in 2013, participants were first recruited into the study through their hockey associations. If the association agreed, the manager and/or coaches of the teams were personally invited to participate and were provided information about the study to distribute to their players. Each player and/or parent on a team individually consented to the study. Continuation in the study and rolling recruitment occurred annually at the start of every season. In 2015-16, the primary prospective studies included 1 Pee Wee team (ages 11- 12), 31 Bantam teams (ages 13-14), and 21 Midget teams (ages 15-17) from Calgary, 22 Bantam and 18 Midget teams recruited from Edmonton, and 37 Midget teams recruited from Vancouver. Individual players in Calgary could also enter the study directly by contacting the study coordinators or participating in hockey camps organized by the research team. In Alberta and British Columbia, school boards and individual hockey associations can choose whether or not they mandate and/or recommend concussion education for their students/athletes.

52 The questionnaire for this study [Concussion Knowledge, Beliefs and Behaviours Questionnaire (CKBBQ)] was completed during baseline testing sessions for the 2015-16 season either on site at the research center or at the rink under the supervision of research assistants. An effort was made to dissuade participants from talking to each other about their responses. Completion of the questionnaires for this study was voluntary and uncompensated. However, participating within the prospective cohort studies allowed participants direct access to study sport physicians in the case of suspected concussions. This may have been considered an incentive by some of the participants. Participants were not required to answer every question. Due to time constraints at some of the baseline testing sessions, there were occasions where players were unable to complete the questionnaire. Therefore, participants with less than 80% of outcome measures complete were removed from the analysis. Ethics approval was received from the research ethics boards at the University of Calgary, University of Alberta and the University of British Columbia.

4.2.2 Theoretical Framework Schwarzer first introduced the Health Action Process Approach (HAPA) in 1992 as a theoretical framework to understand the processes involved in health behaviour change.274 The HAPA has been used to understand how interventions can affect many different types of health behaviours (e.g. neuromuscular programs, physical exercise, seat belt use and dietary behaviours).275 To address the limitation in previous social cognitive models involving the gap between intention and behaviour, the HAPA model proposes post-intentional factors including planning and self-efficacy.273 The HAPA proposes that health behaviour consists of two phases: forming an intention to do the behaviour (motivational phase), followed by a volitional stage of self-efficacy and planning to do behaviour. Given that players may be subjected to environmental and situational factors influencing their intention to report their concussion throughout the season (e.g. playoff, shift in team standings, team expectations), using a theory that examined post-intentional factors was crucial. See Figure 4.1.

53 Figure 4.1 The Health Action Process Approach (Schwarzer 2008)275

Figure 1 4.1 The Health Action Process Approach

Mo%va%onal Phase Voli%onal Phase

Maintenance Recovery Action Self- Self-Efficacy Self-Efficacy Efficacy Ac%on Ac%on Control Outcome Planning Inten%on Expectancy Coping Ac%on Planning Risk Perception

Barriers and Resources, eg. Social Support

4.2.3 Measurement Tool The Concussion Knowledge Beliefs and Behaviours Questionnaire (CKBBQ) is an original tool designed to examine concussion knowledge and specific behaviours related to management using the constructs from the HAPA. The hockey-specific questionnaire was developed based on a review of the literature and updated using the 4th international consensus on concussion in sport and resources provided by Schwarzer et al276,277 on developing HAPA scales. The questionnaire was reviewed by a panel of experts consisting of medical doctors, certified athletic therapists, and senior researchers for face validity and readability. Validation resulted in small changes in word choice. The questionnaire was also pilot tested with a group of Bantam players from Vancouver and Calgary, resulting in one item being removed. Additional questions (not reported in this paper) were added after qualitative interviews with participants to assess the prevalence of reoccurring themes. The full survey took approximately 20 minutes for players to complete.

4.2.4 Study Measures Previous Exposure to Education The primary exposure variable for this study was whether or not a player received concussion information in the last year. This was reported based on the following yes or

54 no question: “In the last year, have you been given information about concussion?”

Concussion Knowledge Concussion knowledge was measured using 32 True or False items assessing knowledge of the concussion definition (i.e. concussion is a brain injury) (1), awareness of risks (3), misconceptions (2), recognition (3), signs and symptoms (8 real symptoms, 8 distractor symptoms), response (3), and recovery and return to play (4). Participants received 1 point for each correct response. The majority of the knowledge questions were adapted from previously validated questionnaires by Rosenbaum & Arnett,278 White et al.,279 Mrazik et al.,280 and Guilmette et al.281 Three additional items were generated to assess participants’ understanding of different responses to potential red flag symptoms. Here red flag symptoms are defined as more serious symptoms that require an immediate visit to the emergency room—this compares to a concussion that can be seen by a family or sport medicine physician. To identify participants not paying attention to the questionnaire, a validity item was added to the true or false section that asked participants to respond to the following statement: “Ice hockey is a game typically played with a puck.” This item was not scored but used to help identify participants that should be removed from the analysis. The internal consistency of the concussion knowledge construct in this sample was ∝= 0.73.

Risk Perception Risk perception was assessed using seven items. Items assessed overall risk perceptions of having a concussion and long lasting complications. Items also assessed player perceptions of the risk to their health associated with not reporting specific symptoms (i.e., headache, neck pain and dizziness). Headache, neck pain, and dizziness were selected as specific symptoms because they have been identified as the most common symptoms following concussion.282 Responses are rated on a scale from 1 (1 Not at all Likely, Not at all Bad) to 7 (Extremely Likely, Extremely Bad). The mean value for all items representing risk perception was used to generate a total risk perception score. Higher scores indicate a greater perception of health risk associated

55 with not performing the target behaviour of reporting concussion symptoms. The internal consistency of this construct in this sample was ∝= 0.84.

Outcome Expectancies Outcome expectancies was assessed using 11 items consisting of previously identified reasons players did not report concussion as potential perceptions of outcomes.265 Negative potential consequences included items related to being perceived as soft, the team losing the game, and teammate and parental disappointment. Positive outcomes included receiving the appropriate care, lowering chances of missing more hockey from a potential concussion, or preventing the injury from getting worse. Responses were rated on a scale from 1 (Strongly Disagree) to 7 (Strongly Agree). The mean value of the items representing positive outcome expectancies and reverse coded negative outcome expectancies generated a total score. Higher scores represent a greater perception of positive outcomes if reporting is performed. The internal consistency of this construct in this sample was ∝= 0.80.

Action Self-Efficacy Action self-efficacy is a measure of the players’ confidence in their ability to report concussion symptoms to an adult. Action self-efficacy was assessed using five items related to the player’s confidence in their ability to tell their coach or parent about concussion symptoms and knowing when to do it. Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree), where the mean value from the items represents a total score for action self-efficacy. A greater score represents higher confidence to do the targeted behaviour. The internal consistency of this construct in this sample was ∝= 0.90.

Maintenance Self-Efficacy Maintenance self-efficacy was assessed using three items related to the players’ confidence in their ability to report symptoms of concussion even at the risk of getting removed from the game under different conditions (even if teammates were counting on them, even if there was an expectation for them to go back into that game, even if it was

56 during the playoffs). Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree), where the mean value from the items generates a total score for maintenance self-efficacy in each subpopulation. A greater score represents greater perceived confidence to deal with barriers that may affect whether the behaviour takes place in diverse situations (e.g., during the playoffs.) The internal consistency of this construct in this sample was ∝= 0.92.

Recovery Self-Efficacy Recovery self-efficacy was assessed using six items related to an athlete’s perceived capability to report the symptoms even after they have been playing through symptoms. Items represent different times (e.g. report after playing one shift, completing a full period, at the end of the game) The items were prefaced by the following statement: “In spite of good intentions, sometimes it’s hard to talk to your coach or parents/guardians right away if you start feeling symptoms of concussion.” Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree) where the mean value from the items generates a total score for recovery self-efficacy in each subpopulation. A greater score represents greater perceived confidence to address failure in performing the targeted behaviour by still doing the behaviour after the suggested appropriate time has passed. The internal consistency of this construct in this sample was ∝= 0.88.

Action Planning Action planning was assessed using three items about whether the athlete knows who to tell, when to tell them, and whether their coach or parents have discussed with them what they are supposed to do if they think they have a concussion. Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree) where the mean value from the items generates a total score. Higher scores represent greater agreement that detailed plans are in place that facilitate doing the behaviour. The internal consistency of this construct in this sample was ∝= 0.71.

57 Behavioural Intention Intention was assessed using two items related to telling a coach or parent about symptoms. Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree). A greater score across the mean of the two items that make up intention represents a greater intention to perform the behaviour. The internal consistency of this construct in this sample was ∝= 0.79.

Self-Reported Retrospective Behaviour Participants were asked to estimate how often they performed specific behaviours throughout the previous season. A dichotomous yes/no question assessed the possibility that the behaviour could have occurred that season. Subsequent questions regarding specific behaviours related to playing through specific symptoms and not reporting were assessed.

Other Explanatory Variables. Additional data were collected by the questionnaires and by the preseason baseline questionnaire from the larger study. These variables include: sex, age group, hockey experience, concussion history, and where they obtained their information about concussion. A full list of the questions for each HAPA construct along with sample frequencies is available in Appendix D.

4.2.5 Analysis Data were analyzed using STATA (v14, College Station, Texas, USA). The significance level alpha was set a priori at 0.05 but adjusted for multiple comparisons performed based on the number of independent tests (p=0.05/10=0.005). Participant characteristics were compared descriptively (frequencies and proportion) between youth ice hockey players who received concussion information in the last year and those that had not received concussion information. The frequency and proportion of participants using specific sources of concussion information as well as their rating of perceived helpfulness are reported. The proportion of individuals with correct responses is reported for all knowledge

58 items by exposure to education. The association between previous education in the last year and player knowledge was examined using multivariable linear regression adjusting for cluster by team, number of previous concussions diagnosed by a physician, and age group (Pee Wee, Bantam or Midget). Covariates were selected based on previous literature that identified previous concussion and age as potential predictors of knowledge.283 Due to the low number of participants with multiple concussions, previous history of concussion diagnosed by a physician was dichotomized (history of concussion, no history of concussion). Statistical modeling was performed using backward elimination examining pairwise interactions between all covariates. Means and standard deviations for all constructs in the HAPA are presented by exposure to education. The association between previous education in the last year and player mean scores for all constructs of the Health Action Process Approach was examined using multivariate linear regression adjusting for cluster by team, number of previous concussion diagnosed by a physician and age group (Pee Wee, Bantam or Midget). Statistical modeling was performed using backward elimination examining single interactions between all covariates. The assumptions of both the final multivariable linear regression model and the final multivariate linear regression model were assessed graphically using Normal Q-Q plots of the residuals and examining the distribution of residuals over the fitted values. To address concerns of a left skewed distribution of conditional means, the models were also analyzed using cubic transformations of the outcome. No differences were found in the significances of the coefficients examining education between models that transformed the outcome measures and those that did not. The association between participant behaviour over the last season and education in the last year was assessed using chi-squared tests for each behaviour. Due to the low number of females, sex was not included as a covariate in full models for either knowledge or HAPA constructs. An exploratory sub-analysis in a small sample of Bantam players from Calgary and Edmonton suggested no significant interaction or confounding effects. For the participant to be included in the analysis, they must have responded the item related to the primary exposures. The number of participants included in each analysis is reported.

59 4.3 Results Of the 1847 participants recruited into the prospective cohort study, 842 (45.6%) players completed the concussion knowledge, belief and behaviour questionnaire (CKBBQ). The main reason for not completing the questionnaire was participant study burden due to other study measures needing to be completed or logistics regarding completion of the questionnaire at different sites. Twenty-four players were excluded because they failed to answer the validity question correctly, 8 players were excluded because they did not answer the question about receiving concussion education, and 12 were excluded because they did not complete at least 8 of the 10 outcome measures on the questionnaire (95% inclusion rate). The final sample included 798 players; 536 (67.2%) were provided information about concussion in the last year. Not all participants answered all questions; thus, the denominators for each outcome of respondents are listed. Table 4.1 describes the participant characteristics by whether they received previous education in the last year. Participants in the two groups were similar on all characteristics except for history of suspected concussion (p=0.002, Fisher’s exact test) and history of diagnosed concussions (p=0.001, Fisher’s exact test). Players reporting a lifetime history of at least one concussion diagnosed by a doctor were more likely to have received concussion information in the last year than those without a history of concussion. [174/226 (77%) versus 362/571(63%), chi-squared= 15.62 p<0.0001].

60 Table 4.1. Characteristics of study participants Table 6 4.1 Characteristics of study participants

Received Concussion No Concussion Education in the last Education in the last year year (n=262) (n=536) Sex Male 249 (95.0%) 511 (95.3%) Female 13 (5.0%) 25 (4.7%) City Calgary 144 (55.0%) 319 (59.5%) Edmonton 90 (34.4%) 169 (31.5%) Vancouver 28 (10.7%) 48 (9.0%) Age Group Pee Wee (ages 11-12) 10 (3.8%) 30 (5.6%) Bantam (ages 13-14) 178 (67.9%) 358 (66.8%) Midget (ages 15-17) 74 (28.2%) 148 (27.6%) Years of Hockey 0 to <5 years 15 (5.7%) 15 (2.8%) >=5 to <10 years 148 (59.9%) 305 (58.5%) >=10 years 97 (33.6%) 212 (40.5%) Missing 2 (0.8%) 4 (0.9%) Number of times participant believed they had a concussion 0 190 (72.5%) 308 (57.5%) 1 44 (16.8%) 132 (24.6%) 2 20 (7.6%) 59 (11.0%) 3 7 (2.7%) 27 (5.0%) 4 1 (0.4%) 8 (1.5%) >4 0 (0.0%) 2 (0.4%) Missing data 0 (0.0%) 0 (0.0%) Number of times participant was told by a physician they had a concussion 0 209 (79.8%) 362 (67.5%) 1 38 (14.5%) 108 (20.1%) 2 12 (4.6%) 44 (8.2%) 3 2 (0.8%) 16 (3.0%) 4 0 (0.0%) 6 (1.1%) >4 0 (0.0%) 0 (0.0%) Missing data 1 (0.4%) 0 (0.0%)

4.3.1 Sources of Concussion Information Table 4.2 describes where youth ice hockey players obtain information from about concussion and how helpful they felt the resource was. The top sources of concussion information reported by youth ice hockey players include parents and guardians (67.4%), participation in the concussion study (52.3%), and their coach (55.1%). Other sources described by participants included brain specialists, other sporting organizations, other healthcare providers, public events, books, and friends. The most

61 helpful resources included doctors, parents, research articles, and the concussion study. Players who had received concussion information in the last year reported receiving concussion information from a median of four sources, ranging between 1-13 sources on the list. Teachers and coaches used in-person presentations most frequently as the method for providing concussion education (154/226, 68.1% and 247/427, 57.8% respectively). The second most common method was videos/DVDs (74/226, 32.7%) for teachers educating their students and fact sheets (335/427, 78.5%) for the coaches. Figure 4.2 illustrates where players would like to get their concussion information from.

62 Table 4.2. The source and helpfulness of concussion information Table 7 4.2: The source and helpfulness of concussion information

Did you get information from the following places? Degree of helpfulness Source of Extremely information n No Yes Not helpful A little Somewhat Very helpful Missing

400 375 5 59 163 113 24 11 Hockey Association 775 (51.6%) (48.4%) (1.3%) (15.7%) (43.5%) (30.1%) (6.4%) (2.9%) 348 427 8 60 154 124 29 52 Coach 775 (44.9%) (55.1%) (1.9%) (14.1%) (36.1%) (29.0%) (6.8%) (12.2%) 252 521 9 79 194 156 70 13 Parent(s)/Guardian(s) 773 (32.6%) (67.4%) (1.7%) (15.2%) (37.2%) (29.9%) (13.4%) (2.5%) 434 337 5 25 66 116 113 12 Doctors 771 (56.3%) (43.7%) (1.5%) (7.4%) (19.6%) (34.4%) (33.5%) (3.6%) 546 226 11 41 57 48 21 48 Teachers 772 (70.7%) (29.3%) (4.9%) (18.1%) (25.2%) (21.2%) (9.3%) (21.2%) 572 199 6 29 71 56 26 11 Research Articles 771 (74.2%) (25.8%) (3.0%) (14.6%) (35.7%) (28.1%) (13.1%) (5.5%) 554 219 18 60 79 47 7 8 TV 773 (71.7%) (28.3%) (8.2%) (27.4%) (36.1%) (21.5%) (3.2%) (3.7%) 681 91 11 26 36 10 7 1 Newspapers 772 (88.2%) (11.8%) (12.1%) (28.6%) (39.6%) (11.0%) (7.7%) (1.1%) Social media 630 141 14 49 50 20 4 4 (Facebook, Twitter) 771 (81.7%) (18.3%) (9.9%) (34.8%) (35.5%) (14.2%) (2.8%) (2.8%) 707 64 8 18 20 15 1 2 Magazines 771 (91.7%) (8.3%) (12.5%) (28.1%) (31.3%) (23.4%) (1.6%) (3.1%) 437 336 12 66 129 82 31 16 Internet 773 (56.5%) (43.5%) (3.6%) (19.6%) (38.4%) (24.4%) (9.2%) (4.8%) 367 402 5 28 68 152 135 14 Concussion Study 769 (47.7%) (52.3%) (1.2%) (7.0%) (16.9%) (37.8%) (33.6%) (3.5%) 686 58 3 11 10 26 Other: 744 (92.2%) (7.8%) (0.0%) (5.2%) 8 (13.8%) (19.0%) (17.2%) (44.8%)

Figure 4.2. Frequency of self-report preferred sources for concussion education Figure 2 4.2 Frequency of self-report preferred sources for concussion education

Healthcare professionals 514

Doctor 501

Coach 413

Parent/guardian 412

Teacher 158

The Internet 155

Other 17

* Note: Participants could select more than one option

4.3.2 Concussion Knowledge Table 4.3 summarizes the proportion of individuals who correctly responded to knowledge questions presented by whether or not they received concussion information in the last year. Knowledge items where the sample percentages of correct items differ by 5 of more are identified in bold. The mean knowledge score for all participants was 23.89/32. Overall, participants scored lowest on items related to appropriate response to the red flag symptom of a worsening headache, the distinction between concussion symptoms and specific distractors (panic attacks, reduced breathing rate and fever), and items related to recovery and return to play. Compared to players who did not receive concussion education, a larger proportion of players who received concussion education were capable of correctly identifying less common symptoms, including feeling slowed down (83.4% versus 74.1%), feeling tired (85.2% versus 78.5%) and feeling in a fog (80.2% versus 67.7%). Based on the multivariable regression adjusting for age group, previous history of one or more concussions, and cluster by team; receiving concussion education in the last year is associated with mean score increase of 1.28 (95%CI: 0.68 to 1.89) in the knowledge score. The final model included 736 participants. Having a history of concussion was also a significant predictor of concussion knowledge score after controlling for previous education, age group, and cluster by team, associated with an estimated mean increase of 0.83 (95%CI: 0.17-1.48) points in knowledge.

64 Table 4.3. Participant knowledge by exposure to previous education Table 8 4.3 Participant knowledge by exposure to previous education No Previous Previous Concussion Concussion Total Total Education Education Sample n Correct n Correct n Correct n (%) (%) (%) Definition 249 504 753 A concussion is a brain injury (T) 784 (96.9%) (95.6%) (96.0%) Understanding the risk of concussion There is a higher risk of long term problems if someone has a 240 498 738 second concussion before recovering from the first one. (T) 796 (91.6%) (93.3%) (92.7%) People who have had one concussion are more likely to have 200 440 640 another concussion. (T) 798 (76.3%) (82.1%) (80.2%) There will be few risks to my health when I am older if I have 151 331 482 many concussions. (F) 791 (57.9%) (62.5%) (60.9%) Misconceptions Sometimes a second concussion can help a person remember 212 453 665 things that were forgotten after the first concussion. (F) 797 (81.2%) (84.5%) (83.4%) 217 476 693 There are helmets that prevent all concussions. (F) 795 (83.8%) (88.8%) (87.2%) Recognition 158 401 559 Concussions can sometimes lead to emotional problems. (T) 795 (61.0%) (74.8%) (70.3%) 256 524 780 To have a concussion, you have to be knocked out. (F) 798 (97.7%) (97.8%) (97.7%) A concussion can only occur if there is a direct hit to the head 213 477 690 (F) 796 (81.6%) (89.2%) (86.7%) Signs and Symptoms 221 496 717 Hives (N) 793 (85.3%) (92.9%) (90.4%) 254 530 784 Headache (Y) 795 (97.7%) (99.1%) (98.6%) 123 280 403 Fever (N) 795 (47.3%) (52.3%) (50.7%) 207 465 672 Arthritis (N) 794 (79.9%) (86.9%) (84.6%) 235 506 741 Sensitivity to Light (Y) 794 (90.4%) (94.8%) (93.3%) 245 514 759 Difficulty Remembering (Y) 794 (94.6%) (96.1%) (95.6%) 155 292 447 Panic Attacks (N) 795 (59.6%) (54.6%) (56.2%) 204 455 659 Feeling Tired (Y) 794 (78.5%) (85.2%) (83.0%) 176 429 605 Feeling in a Fog (Y) 795 (67.7%) (80.2%) (76.1%) 211 443 654 Weight Gain (N) 792 (81.5%) (83.1%) (82.6%) 192 446 638 Feeling Slowed Down (Y) 794 (74.1%) (83.4%) (80.4%) 123 244 367 Reduced Breathing Rate (N) 794 (47.3%) (45.7%) (46.2%) 192 423 615 Excessive Studying (N) 794 (73.8%) (79.2%) (77.5%) 236 509 745 Difficulty Concentrating (Y) 790 (91.8%) (95.5%) (94.3%) 248 527 775 Dizziness (Y) 794 (95.4%) (98.7%) (97.6%) 234 489 723 Hair Loss (N) 792 (90.0%) (91.9%) (91.3%)

Table 4.3. Participant Knowledge by exposure to previous education (Continued)

No Previous Previous Concussion Concussion Total Total Education Education Sample n Correct n Correct n Correct n (%) (%) (%) Response After a collision, body check, or fall a player starts 218 456 674 throwing up over and over again. (ED) 796 (83.2%) (85.4%) (84.7%) After a collision, body check, or fall a player has a 75 142 217 headache that continues to get worse. (ED) 795 (28.6%) (26.6%) (27.3%) Immediately after a collision, body check, or fall a player complains of a headache and dizziness but starts to feel 148 338 486 better by the end of the game. (NU) 796 (56.5%) (63.3%) (61.1%) Recovery and Return to Play Younger players (under the age of 18) typically take 65 146 211 longer to recover from a concussion than adults. (T) 795 (24.9%) (27.3%) (26.5%) Post-concussion symptoms can be delayed for hours or 171 379 550 days. (T) 792 (65.5%) (71.4%) (69.4%) An athlete can return to play while experiencing symptoms of a concussion if directed to do so by an 125 276 401 athletic trainer or a physician (doctor). (F) 796 (48.1%) (51.5%) (50.4%) Have you heard of the term “graduated return to play 19 105 124 protocol” or "stepwise return to play" for concussion? (Y) 798 (7.3%) (19.6%) (15.5%) Total Score, Mean (SD)1 737 22.97 (3.83) 24.33 (3.59) 23.89 (3.72) Abbreviations: T-True; F-False; Y-Yes; N-No; DN-Do nothing; NU-Non-Urgent, book an appointment with a physician; ED-Go to the emergency department 1 There were 239/737 participants with no history of concussion education and 498/737 with a history of concussion education Items that are in bold had greater than a 5% difference in the proportion of correct responses between those who had received concussion education and those that had not received concussion education

4.3.3 Constructs of the Health Action Process Approach

Summary statistics for the constructs in the Health Action Process Approach stratified by exposure are presented in Table 4.4. Based on the multivariate analysis, after adjusting for previous concussion history and age group, previous education was not significantly associated with any of the constructs at an alpha level of 0.005. However, having a history of concussion was significantly associated with a 0.18 (95%CI: 0.08 – 0.41) point increase in the planning construct. Full results from the multivariate analyses are presented in Table 4.5.

66 Table 4.4 Summary Statistics of the Health Action Process Approach constructs by exposure to education Table 9 4.4 Summary statistics of the Health Action Process Approach constructs by exposure to education

Provided No concussion concussion information in the information in the Outcome last year last year Total Number Estimated Estimated Estimated of Items n Mean (SD) n Mean (SD) n Mean (SD) Risk Perception 7 256 5.10 (0.98) 521 5.21 (0.98) 777 5.18 (0.98) Outcome Expectancies 11 249 6.02 (0.98) 517 6.01 (0.75) 766 6.01 (0.78) Action Self-Efficacy 2 261 6.28 (1.03) 534 6.28 (0.98) 795 6.28 (1.00) Intention 2 261 5.93 (1.23) 535 6.00 (1.23) 796 5.98 (1.23) Maintenance Self- Efficacy 3 259 5.63 (1.34) 532 5.46 (1.52) 791 5.51 (1.46) Recovery Self-Efficacy 6 259 5.28 (1.55) 256 5.35 (1.58) 785 5.32 (1.57) Planning 3 255 5.94 (1.12) 524 6.18 (0.99) 779 6.10 (1.04)

Table 4.5. Associations between HAPA constructs and education, previous concussion and age group based on multivariable linear regression Table 10 4.5 Association between HAPA constructs and education, previous concussion and age group based on multivariate linear regression

Recovery Outcome Action Self- Maintenance Self Risk Perception Expectancies Efficacy Intention Self-Efficacy Efficacy Planning Predictors, coefficient (95%CI) Previous Education (yes) 0.09 -0.03 -0.08 0.03 -0.18 0.06 0.18 (-0.06, 0.25) (-0.15, 0.09) (-0.23, 0.08) (-0.16, 0.22) (-0.41, 0.06) (-0.19, 0.31) (0.02, 0.34) Concussion History (yes) 0.06 -0.11 0.12 -0.04 -0.09 -0.17 0.24* (-0.10,0.21) (-0.24, 0.02) (-0.04, 0.29) (-0.24, 0.16) (-0.33, 0.15) (-0.43, 0.09) (0.08, 0.41) Level of play (Bantam) -0.11 0.09 0.1 -0.18 -0.24 0.06 -0.17 (-0.45,0.22) (-0.18, 0.36) (-0.24, 0.44) (-0.60, 0.23) (-0.74, 0.26) (-0.47, 0.60) (0.08, 0.41) Level of play (Midget) -0.09 0.09 0.17 -0.16 -0.11 0.5 -0.17 (-0.44, 0.26) (-0.19, 0.37) (-0.18, 0.52) (-0.59, 0.28) (-0.64, 0.41) (-0.06, 1.06) (-0.52, 0.17) Level of play (Pee Wee) reference reference reference reference reference reference reference _constant 5.21 6.00 6.2 6.17 5.88 5.18 6.04 (4.87, 5.55) (5.72, 6.27) (5.86, 6.55) (5.75, 6.60) (5.36, 6.40) (4.63, 5.74) (5.68, 6.39) R -squared 0.004 0.005 0.006 0.001 0.007 0.018 0.031 Observations 699 699 699 699 699 699 699 *p<0.005

68 4.3.4 Self-reported Player Behaviour The proportion of players who reported experiencing dizziness, headache, or neck pain, or felt like they may have had a concussion in the last year, was slightly higher for those who were provided concussion information in the last year than for those who did not receive education (35.8% versus 19.8% respectively, chi-squared =21.187, p<0.0001). There was no association between players playing through headache, dizziness, or neck pain, or not telling their parents or coach about their symptoms, and education in the last year. The proportion of players who reported at least one instance of specific playing or reporting behaviours are described in table 4.6.

69 Table 4.6. Summary of player behaviours by whether or not they received concussion education in the last year

Table 11 4.6 Summary of player behaviours by whether or not they received concussion education in the last year

No concussion Provided concussion information in the last information in the last Chi Outcome year year Total square p n Proportion n Proportion n Proportion

Over the last hockey season (2014-2015), did you experience dizziness, headaches, neck pain or feel like you may have a concussion after a hard fall, 51 190 241 collision, or body check? 258 (19.8%) 530 (35.8%) 788 (30.6%) 21.1386 <0.0001 Proportion of players in which the following behaviours occurred after a hard fall, collision, or body check at least 1 time in the last season Player experienced dizziness, and continued to play 29 94 123 in a game 49 (59.2%) 189 (49.7%) 238 (51.7%) 1.391 0.238 Player experienced dizziness, and continued to play 13 48 61 in a practice 49 (26.5%) 189 (25.4%) 238 (25.6%) 0.026 0.871 Player experienced a headache, and continued to 31 132 163 play in a game 49 (63.3%) 189 (69.8%) 238 (68.5%) 0.780 0.377 Player experienced a headache, and continued to 20 73 93 play in a practice 49 (40.8%) 189 (38.6%) 238 (39.1%) 0.079 0.779 Player experienced neck pain, and continued to play 17 67 84 in a game 49 (34.7%) 188 (35.6%) 237 (35.4%) 0.015 0.902 Player experienced neck pain, and continued to play 9 40 49 in a practice 49 (18.4%) 188 (21.3%) 237 (20.7%) 0.201 0.654 Player felt like they had a concussion, and didn’t 06 37 43 tell their coach 49 (12.2%) 188 (19.7%) 237 (18.1%) 1.447 0.229 Player felt like they had a concussion, and didn’t 4 24 28 tell their parents 49 (8.2%) 188 (12.8%) 237 (11.8%) 0.790 0.374

70 4.4 Discussion This is the first study to examine how previous exposure to education affects potential motivators of player reporting under the scope of the Health Action Process Approach in a sample of Canadian youth ice hockey players. The findings suggest that while receiving concussion information in the last year appears to be slightly associated with greater knowledge, it is not associated with differences in the belief constructs that have been identified as predictors of health behaviour change. Furthermore, being exposed to education in the last year was not associated with any differences in player management behaviour. These results are consistent with several studies that demonstrate that previous education may not affect player knowledge and that the effects of education on knowledge and attitudes may not persist in the long-term.284,285 Previous educational interventions using strategies to affect belief constructs have resulted in immediate effects on attitudes in youth ice hockey players. For example, an educational program provided to elite Bantam and Midget AA hockey players that used multiple methods of dissemination including personal testimonials resulted in immediate changes in knowledge and attitudes that remained 3 months following the intervention.263 Personal testimonial is a form of persuasion that can be used in the motivational phase.286 Concussion education is not the only factor that can influence a player’s intention to report symptoms. Previous studies have shown high pressure to play from parents, coaches, teammates, and fans lower a player’s intention to report symptoms.287 On the other hand, coaches who create a supportive environment for their athletes can increase a player’s willingness to report.288 This study provides a preliminary view about how a player’s previous exposure to education affects their knowledge and current beliefs. If the intended goal of policy makers is to implement concussion education that aims to change player-reporting behaviours, educational programs should be framed with behaviour change in mind. For example, education that includes persuasive messaging, modelling, and restructuring of the social and physical environment may assist with this goal.289 Interventions can also be tailored based on an individual player’s stage of change (motivational or volitional).

71 4.5 Limitations The participants were not randomly selected but rather recruited from within another study. This allowed a large community sample of male youth ice hockey players to be represented. However, participants willing to participate in a study that examines injury risk may have greater risk perceptions and increased awareness related to concussion. The larger prospective study also provides direct access to sport medicine physicians for diagnosis, and this may have increased measures of self-efficacy and action planning across all participants. Since a focus of the larger study was on body checking, female participants are poorly represented in this study. More studies are needed to demonstrate how sex affects these measures. A primary limitation of the study is the inability to adjust for type, description, or timing of education received in the last year. While quantifying the exposure as educated or not reflects the nature of blanket educational policies that allow individual associations, schools, and teams to select their education format, prospective research is needed to better control for both the short-term and long-term effects of education using behaviour change paradigms as a framework versus other forms of education. There is also a possibility of misclassification bias associated with players not accurately remembering when they received concussion information. This study assumes that the players answered the questionnaires truthfully and without outside influence. It further assumes that the questionnaires are valid and reliable. The CKBBQ was developed for the purposes of this study based on previously validated questionnaires and then pilot tested. However, some of the distractor symptoms previously used in the literature can be associated with concussion but are not considered a symptom of concussion. For example, only 23% of parents and coaches correctly identified panic attacks as not a symptom of concussion. Increased anxiety/nervousness following concussion may have lead individuals to believe a panic attack is a symptom. Self-reported measures of behaviour may be subject to recall bias and social desirability bias. Due to the cross-sectional study design, one of the limitations of this study is the inability to know the directionality of the relationship between previous concussion

72 education and players’ beliefs about concussion and behaviours when a concussion is suspected.

4.6 Conclusion The current findings suggest that receiving concussion education within the last year is not associated with significant differences in beliefs related to appropriate reporting behaviour in youth ice hockey players. Concussion education may however be associated with small changes in knowledge. Blanket policies that do not guide the type of education received may not have the intended affects. Further research that is longitudinal in nature and examines educational strategies specifically targeting the motivators of behaviour and grounded in health behaviour change theory is needed.

Chapter 5: Does receiving information about concussion affect concussion management knowledge, beliefs and/or behaviours? Part 2: Youth ice hockey parents and coaches

74 5.1 Introduction

It is estimated that between 1.6 and 1.9 million children and youth sustain a sport- related concussion annually within the United States alone.250 Often affecting an adolescent’s activities of daily living as well as his or her ability to function in school, symptoms of concussion can be somatic, cognitive, and/or emotional.21 The majority of children who sustain a concussion appear to recover normally within a few weeks to a month without secondary complications.21,23 However, approximately 15 to 30% of children may have prolonged symptoms lasting longer than one month—a condition referred to as post-concussion syndrome.23 Furthermore, if a concussion is not managed appropriately it can lead to more severe consequences including prolonged recovery, long term complications and in rare cases death.17,21,35,36 Although primary prevention of the initial concussion is ideal, it is not always possible in youth sport. Therefore, secondary prevention strategies aimed at the recognition of the concussion and appropriate management have become a focus of policy, and concussion education has been identified as an essential tool.259 Appropriate sideline management of the injury requires both recognizing that a concussion has occurred and removing the athlete from play.21 In youth sport, however, many teams do not have access to healthcare providers on the sidelines. Thus, parents, players, and coaches can play a crucial role in recognizing the injury, removing the athlete from play and supporting appropriate management and return to school and play following concussion. The majority of previous research on concussion education has focused on the effects of an athlete’s concussion knowledge on their willingness to report symptoms to a coach or parent.265,290 However, in some cases players may not report their symptoms or recognize a concussion has occurred and the responsibility lies with the coach to recognize a suspected concussion, remove the athlete from the game or practice, and inform the parents that their child should see a physician for diagnosis and management.291 It is then up to the parent to take their child in to see a physician for assessment and clearance to return to school and play. In some instances, concussion symptoms are delayed and may go undetected by the coach.21 In this case it is up to the

75 parent to recognize their child may have sustained a concussion and seek care. Experts postulate that learning about concussion, being able to identify the signs and symptoms of concussion, identifying what mechanisms can cause concussion, knowing how to respond to a concussion, and knowing when to safely return to play should lead to proper management.21 However, the beliefs of parents and coaches can affect whether or not they respond appropriately.33 These beliefs can best understood within the context of behaviour change models and can include, but are not limited to; the perception of risks of negative outcomes associated with a given behavioural response, expectation of what will happen if they perform the desired behaviour, and perceived confidence in their ability to perform the behaviour.34 There is some evidence to suggest that providing concussion education can increase coach and parent knowledge.247,285,291–295 However, the evidence surrounding the effect of concussion education on beliefs or behaviours of parents and coaches is sparse, and has only been conducted in the United States.247,293 Among the studies examining the effect of concussion education in coaches and parents, only one study in parents and one study in coaches attempted to use behaviour change theory in the development or evaluation of the education.247,293 These studies have attempted to examine concussion education within the context of the theory of planned behaviour or the health belief theory. These theories can assist with evaluating the impact of concussion education on the motivators of intention to do a specific behaviour, however, intention does not always coincide with the execution of behaviour.247,293 The motivational phase/pre-intentional phase of the Health Action Process Approach is similar to the theory of planned behaviour but also proposes planning and self-efficacy around maintaining behaviour in different circumstances as key mechanisms for addressing the intention to behaviour gap. Given potential differences in attitudes and beliefs between Canada and the United States as well as the limitations associated with the theory of planned behaviour, more research is needed in different populations using different models. Currently in Canada, most provinces do not have provincial legislation surrounding mandatory concussion education, although individual sporting associations can decide whether to provide coaches or parents with concussion education. In order to make recommendations regarding future changes to concussion education policies, it is

76 important to understand the effect of providing concussion education on both knowledge of concussion and beliefs related to concussion management behaviour. This issue is especially important in Canadian youth ice hockey where there are high participation rates and one of the highest rates of concussion.1,12 Therefore, the primary objective of this study is to examine the association between self-reported prior exposure to concussion education and knowledge, beliefs and self-reported management behaviour among the parents and coaches of youth ice hockey players (ages 11-17) under the scope of the Health Action Process Approach. A secondary objective is to describe where hockey parents and coaches receive information, how helpful they find the information provided, and where they would like to receive further concussion education. Most of the available educational materials on concussion have been designed with the goal of knowledge translation and not with the tenets of behaviour change theory in mind. As such, the authors hypothesized that parents and coaches who received concussion education may have increased knowledge about concussion, but may not display differences in beliefs or behaviours related to taking their child into a physician for assessment and clearance (parent) as well as removing a player from play (coach) before and after exposure to educational materials.

5.2 Methods

5.2.1 Sample and Procedure Parents and coaches of youth ice hockey players (ages 11-17) were identified through their child’s or team’s participation in two prospective cohort studies designed primarily to assess risk factors for concussion in youth ice hockey. The prospective cohort studies began in 2013, with recruitment annually at the start of the hockey season or through enrolment in hockey research camps organized by the research team. The questionnaires for this study [Concussion Knowledge, Beliefs and Behaviour Questionnaire (CKBBQ: parent and coaches, CKBBQ: coaches (non-parent)] were introduced at the start of the 2015-16 season. There were two versions of the questionnaire: one for parents of youth ice hockey players and one for youth ice hockey coaches who did not have children participating in the sport. The parent questionnaire

77 was provided to all parents of players participating in baseline testing for the prospective cohort study as part of the package of forms to complete prior to their child’s assessment and to be completed at home. Parents who were also coaches of Bantam or Midget teams that season were asked to complete an additional set of questions related to coach beliefs and behaviours attached to the parent questionnaire. A separate coach version of the form, excluding parent beliefs was provided to coaches of teams who were not parents of children participating in hockey. The coach forms were provided along with the team packages to the team designates who were assisting with organizing the team’s participation in the prospective cohort study. Each parent or coach on a team individually consented to the study and received a package. Only one parent per player was requested to complete the questionnaire. There were no financial benefits offered to parents and coaches who completed this questionnaire. However, as part of the larger prospective study parents could receive expedited access to a sport medicine professional if their child suffered a concussion while in the study. This may have been considered an incentive by some of the participants. Participants were not required to answer every question or complete all the forms provided. Ethics approval was received from the research ethics boards at the University of Calgary, University of Alberta and the University of British Columbia.

5.2.2 Theoretical Framework Schwarzer first introduced the Health Action Process Approach (HAPA) in 1992 as a theoretical framework to understand the processes involved in health behaviour change.274 In order to address the limitation in previous social cognitive models of an intention-behaviour gap, the HAPA model proposes post-intentional factors including planning and self-efficacy.273 The HAPA has been previously used to understand how interventions can affect many different types of health behaviours (e.g. neuromuscular programs, physical exercise, seat belt use and dietary behaviours)275 The HAPA proposes that health behaviour consists of two phases: forming and intention to do the behaviour (motivational phase) followed by a volitional stage of self-efficacy and planning to do behaviour. Given that parents and coaches may be subjected to environmental and situational factors influencing a parent’s intention to take their child to a physician for

78 assessment and clearance (e.g., scheduling conflicts, resistance from the child, playoff season) or a coach’s intention of removing a player from play (e.g., playoff season, parent expectations, player’s insistence on playing), using a theory that examined post- intentional factors was considered important. Figure 5.1 describes the HAPA model and relationship between the constructs.

Figure 5.1 The Health Action Process Approach (Schwarzer 2008)275 Figure 3 5.1 The Health Action Process Approach

Mo%va%onal Phase Voli%onal Phase

Maintenance Recovery Action Self- Self-Efficacy Self-Efficacy Efficacy Ac%on Ac%on Control Outcome Planning Inten%on Expectancy Coping Ac%on Planning Risk Perception

Barriers and Resources, eg. Social Support

5.2.3 Measurement Tool The Concussion Knowledge Beliefs and Behaviours Questionnaire (CKBBQ) is an original tool designed to examine concussion knowledge and specific behaviours related to concussion management using the constructs from the Health Action Process Approach. There is a specific version for parents and parent coaches, and another version for coaches who are not parents. Both of these versions were designed to assess beliefs related to specific behaviours for management (coach removing the athlete from play, parent taking the child to a physician.) The sport-specific questionnaires were developed using a review of the literature adapted to the 4th International Consensus on Concussion in sport and the resources provided by Schwarzer et al276,277 on developing HAPA scales. Knowledge questions were adapted from previous questionnaires by Rosenbaum & Arnett,278 White et al.,279 Mrazik et al.,280 and Guilmette et al.281 Outcome expectancies specific to the youth ice hockey parent and coach population were determined based on

79 the qualitative work by Echlin et al32 and extended and modified using qualitative interviews. The questionnaires were face validated by concussion experts, researchers familiar with the injury, and questionnaire development experts. They were pilot tested with a group of parents in Vancouver and Calgary for readability and option response verification where parents and coaches were encouraged to provide comments. Cognitive interviews with three parents were also conducted where participants were asked to talk aloud as they are filling out the questionnaire to assess if they were interpreting things as the survey intended. Additional questions, not reported in this paper were added to the tool after qualitative interviews with participants to assess the prevalence of reoccurring themes. The full survey took approximately 25 minutes for parent coaches to complete, 20 minutes for coaches to complete and 15 minutes for parents with no coaching experience to complete.

5.2.4 Study Measures Previous Exposure to Concussion Education The primary exposure variable for this study was whether the parent or coach had ever received concussion information. This was reported based on the following yes or no question: “Have you ever received information about concussion?” Parents and coaches were also asked whether the information was provided the current 2015-2016 season.

Concussion Knowledge Concussion knowledge was measured using 32 True or False items assessing knowledge of the concussion definition (a concussion is a brain injury) (1), awareness of risks (3), misconceptions (2), recognition (3), signs and symptoms (8 real symptoms, 8 distractor symptoms), response (3), and recovery and return to play (4). Participants received one point for each correct response. The majority of the knowledge questions were adapted from previously validated questionnaires by Rosenbaum & Arnett,278 White et al.,279 Mrazik et al.,280 and Guilmette et al.281 Three additional items were generated to assess participants’ understanding of different responses to potential red flag symptoms. Here, red flag symptoms are defined as more serious symptoms that require an immediate visit to the emergency room—this compares to a concussion which can be seen by a family or sport medicine physician. The internal consistency of this outcome in this

80 sample was ∝= 0.71. In order to identify participants not paying attention to the questionnaire, a validity item was added to the true or false section that asked participants to respond to the following statement: “Ice hockey is a game typically played with a puck.” This item was not scored but was used to help identify participants for removal from the analysis. Parent and coach versions contained the same questions assessing concussion knowledge.

Risk Perception Risk perception was assessed on a seven-point Likert scale. There were seven items assessing parent risk perception. These items assessed the overall risk perception of their child sustaining a concussion in ice hockey and having long-lasting consequences following a concussion. There were also items related to parents’ perception of impact severity on their child’s health associated with not being assessed and cleared by a physician after a suspected concussion or specific signs and symptoms (e.g., headache, unsteady on their feet, dizziness) following a potential concussion mechanism (e.g., hard fall, collision or body check). Risk perception for the coaches was also assessed using seven items. The initial three items assessed the coaches’ perception of the likelihood for a player to sustain a concussion, have lasting consequences and experience negative health effects following continued play in a game or practice after the incident. Specific items for the coach also assessed the perception of a detriment to a player’s recovery after continuing to play with specific signs and symptoms (e.g., headache, unsteady on their feet and dizziness) following a potential concussion mechanism. Responses are rated on a scale from 1 (Not at all Likely, Not at all Bad) to 7 (Extremely Likely, Extremely Bad). Calculating a mean value from all items representing the risk awareness construct for each set of items generates a total risk awareness score. This calculation was done separately for parents and coaches. Higher scores indicate a greater perception of health risk associated with not performing the target behaviour (Parents: taking their child in to a physician for assessment and clearance, Coaches: removing a suspected player from play). The internal consistency of this construct in this sample was ∝= 0.68 for the parents and ∝= 0.75 for the coaches.

81 Outcome Expectancies Outcome expectancies for parents were assessed using eight items consisting of previously identified reasons parents may not take their child in for an assessment and get clearance from a physician. Potential negative consequences included: the parent feeling they would be wasting their money spent on their child playing hockey, their child will be angry with them, their child will lose their spot on the team, they will miss too much work or the doctor will not tell them anything new. Positive outcomes included: reducing the chances of their child sustaining another concussion, reducing their child’s chances of making their injury worse and missing more hockey, and helping their child stay healthy. Outcome expectancies related to coaches’ behaviour of removing the player from play due to a suspected concussion was assessed using six items. Negative potential consequences included: their team might lose the game, the parent of the player would be angry their child is not playing, the parent of the player would question their decision. On the other hand, positive potential consequences included items that stated removal from play would: reduce the chances of a player sustaining another concussion, reduce the chances of making the players concussion worse, and help the player recover more quickly. Responses were rated on a scale from 1 (Strongly Disagree) to 7 (Strongly Agree). The mean value from the items representing positive outcome expectancies and reverse coded negative outcome expectancies generated a total score. Higher scores represent a greater perception of positive outcomes if the behaviour is performed. The internal consistency of this construct in this sample was ∝= 0.64 for the parents and ∝= 0.60 for the coaches.

Action Self-Efficacy Action self-efficacy is a measure of the parents’ confidence in recognizing when a suspected concussion occurs and feeling capable of being able to get their child to an appointment with a physician for a suspected concussion if needed. This was measured using two items for the parents. Action self-efficacy for coaches was related to their self- rating of their ability to recognize if their player has a concussion, make the decision to remove from play and stop their players from playing if a concussion is suspected (3 items). Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly

82 Agree) where the mean value from the items represents a total score for action self- efficacy. A greater score represents higher confidence to do the targeted behaviour. The internal consistency of this construct in this sample was ∝= 0.60 for the parents and ∝= 0.80 for the coaches.

Maintenance Self-Efficacy. Maintenance self-efficacy is a measure of the parent’s confidence of their ability to get their child to visit a physician for assessment and clearance following a concussion even if situational factors make it more challenging. Examples of the situations assessed include that the parent has somewhere else they have to be, the child doesn’t want to go to the appointment or it is playoff season. For coaches, maintenance self-efficacy refers to their confidence to remove the player following a suspected concussion even if it’s a playoff game, the parents get upset or the player says they are fine. Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree) where the mean value from the items generates a total score for maintenance self-efficacy in each subpopulation. A greater score represents greater perceived confidence to deal with barriers that may affect whether the behaviour takes place in diverse situations (e.g., during the playoffs.) The internal consistency of this construct in this sample was ∝= 0.95 for the parents and ∝= 0.92 for the coaches.

Recovery Self-Efficacy Recovery self-efficacy was assessed using two items related to a parent’s confidence in their ability to get their child assessed and cleared by a doctor even if the concussion is not recognized right away. For coaches, recovery self-efficacy is measured using 2 items related to removing a player from play even if it was not done right away. Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree) where the mean value from the items generates a total score for recovery self-efficacy in each subpopulation. A greater score represents greater perceived confidence to address failure in performing the targeted behaviour by still doing the behaviour after the suggested appropriate time has passed. The internal consistency of this construct in this sample was ∝= 0.84 for the parents and ∝= 0.78 for the coaches.

Planning Action planning is assessed using 2 items for parents and 2 items for coaches. The construct represents participants’ agreement that they have plans in place to do the target behaviour (e.g., standardized protocol for removal from play for the coaches, and parents having a plan related to who their child will see for a concussion). Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree) where the mean value from the items generates a total score for action in each subpopulation. Higher scores represent greater agreement that detailed plans are in place that facilitate doing the behaviour. The internal consistency of this construct in this sample was ∝= 0.79 for the parents and ∝= 0.87 for the coaches.

Behavioural Intention Intention was assessed using 2 items related to a parent taking their child in to a physician for assessment and clearance and 2 items related to a coach removing a player from play if a concussion is suspected. Items are scored on a seven-point Likert scale (Strongly Disagree – Strongly Agree). A greater score across the mean of the two items that make up intention represents a greater intention to perform the behaviour. The internal consistency of this construct in this sample was ∝= 0.91 for the parents and ∝= 0.98 for the coaches.

Self-Reported Retrospective Behaviour The last section of the CKBBQ assesses a participant’s estimation of how often they performed the targeted behaviours over the last season. A dichotomous yes/no question assessed the possibility that the behaviour could have occurred last season. The number of participants who did the behaviour over the number of possible opportunities is examined. The primary behaviours are related to a parent seeking medical attention for his or her child’s concussion for assessment and clearance, or a coach removing an athlete from play. Concussion education behaviour is also described for all participants.

84 Other Explanatory Variables Additional variables were collected by the CKBBQ and by the preseason baseline questionnaire from the two prospective cohort studies. These variables include: coaching experience, age, hockey playing experience, hockey concussion history of their child, hockey history, previous history of concussion education and where they get their information about concussion. Due to some of the conflicting evidence on prevention, additional questions were added to assess parent and coach’s beliefs about prevention, but not included in the assessment of knowledge. For example, parents were asked if they believed neck strengthening, using a mouth guard and/or regulated equipment prevented concussions.

5.2.5 Analysis Data were analyzed using STATA (v14, College Station, Texas, USA). The significance level alpha was set a priori at 0.05 but adjusted for multiple comparisons performed based on the number of independent tests for parents (p=0.05/17=0.002) and for coaches. Participant characteristics were compared descriptively (frequencies and proportion) between parents and coaches who received concussion information and those that had not received concussion information. The frequency and proportion of participants using specific sources of concussion information as well as their rating of perceived helpfulness are reported. In order to understand the characteristics of the coaches who completed the section of the questionnaire on coach beliefs and behaviours a separate table describing respondent characteristics is reported. The proportion of individuals with correct responses is reported for all knowledge items by exposure to education. The association between previous education and total coach and parent knowledge was examined using multivariable linear regression adjusting for cluster by team, coaching experience, first aid experience and a history of managing a child’s concussion. Previous exposure to managing a child’s concussion was dichotomized due to the low number of parents who managed more than one concussion. Statistical modeling was performed using backward elimination examining pairwise interactions between primary exposure (received concussion education) and each

85 covariate. Due to a low response rate, age was not included as a covariate in full model. The assumptions of the final multivariable linear regression model were assessed graphically using Normal Q-Q plots of the residuals and examining the distribution of residuals against the fitted values. Medians and interquartile ranges for all constructs in the HAPA are presented by exposure to education. Due to concerns regarding the distribution of the HAPA constructs relative to the exposure, non-parametric Wilcoxon rank-sum test was used to examine the association between education and constructs related to the HAPA model. The association between parent and coach behaviour over the last season and education in the last year was assessed using chi-squared tests. The number of participants included in each section is reported.

5.3 Results Of the 1847 players (N=130 teams) recruited into the two prospective cohort studies, 809 parents and 11 non-parent coaches completed the CKBBQ. One non-parent coach and 17 parents did not accurately complete the validity question on the questionnaire and were excluded. Three forms were completed incorrectly by both mother and father or for a different sport and were excluded. Three parents did not complete the question on whether they received previous concussion education and were also excluded. The final sample included 786 parents, 250 (31.8%) with coaching experience and 10 non-parent coaches (1.3%). In total, 649 participants had received information on concussion and of those, 195 (30.1%) participants received the information the current season. A total of 134 coaches and parent coaches completed the questions on coach beliefs and behaviour. It is important to note that not all participants answered all questions, thus the denominators for each outcome of respondents is listed. Table 5.1 describes the participant characteristics of parents and coaches who completed the questionnaire stratified by whether or not they received previous education. Very few non-parent coaches completed the questionnaires and a greater proportion of mothers completed the questionnaires then fathers. Participant age ranged from 21 to 61 years of age. All six non-parent assistant coaches and three of the head coaches were under the age of 29. Overall, the majority of participants (73.4%) had been hockey parents for

86 greater than 7 years and those with greater than 7 years of experience with being a hockey parent were more likely to have received concussion education.

87 Table 5.1. Characteristics of all study participants Table 12 5.1 Characteristics of all study participants

Received No Concussion Concussion Education Education (n=147) (n=649) Participant Type Mother 90 (61.2%) 353 (54.4%) Father 52 (35.4%) 279 (43.0%) Non-Parent Head Coach 0 (0.0%) 4 (0.6%) Non-Parent Assistant Coach 1 (0.7%) 5 (0.8%) Missing 4 (2.7%) 8 (1.2%) Coaching Experience No Coaching Experience 115 (78.2%) 421 (64.9%) Coaching Experience 32 (21.8%) 228 (35.1%) Sex of child in study Male 136 (92.5%) 621 (95.7%) Female 11 (7.5%) 28 (4.3%) Hockey Playing Experience No experience 99 (67.3%) 356 (54.9%) Currently plays hockey 21 (14.3%) 128 (19.7%) Used to play hockey 27 (18.4%) 164 (25.3%) Missing 0 (0.0%) 1 (0.2%) City Calgary 85 (57.8%) 436 (67.2%) Edmonton 58 (39.5%) 209 (32.2%) Vancouver 4 (2.7%) 4 (0.6%) Age, mean (SD) 45.22 (5.64) 45.81 (5.39) Missing 23 (15.6%) 107 (16.5%) Age Group Pee Wee (ages 11-12) 2 (1.4%) 36 (5.5%) Bantam (ages 13-14) 113 (76.9%) 457 (70.4%) Midget (ages 15-17) 32 (21.8%) 156 (24.0%) Participant's Highest Level of Education Some grade school 2 (1.4%) 9 (1.4%) High school 16 (10.9%) 76 (11.7%) Bachelor’s degree 40 (31.0%) 213 (36.0%) Graduate degree 18 (12.2%) 96 (14.8%) College 53 (41.1%) 197 (33.3%) Other 9 (6.1%) 28 (4.3%) Missing 9 (6.1%) 30 (4.6%)

88 Table 5.1. Characteristics of all study participants (Continued)

No Concussion Education Received Concussion (n=147) Education (n=649) Years as a Hockey Parent First season 1 (0.7%) 2 (0.3%) 1 year 0 (0.0%) 1 (0.2%) 2 years 0 (0.0%) 3 (0.5%) 3 years 5 (3.4%) 2 (0.3%) 4 years 5 (3.4%) 17 (2.6%) 5 years 6 (4.1%) 26 (4.0%) 6 years 11 (7.5%) 35 (5.4%) 7 years 24 (16.3%) 58 (8.9%) >7 years 92 (62.6%) 492 (75.8%) Missing/Coach 3 (2.0%) 13 (2.0%) Number of Children in Hockey

1 86 (58.5%) 339 (52.2%)

2 46 (31.3%) 235 (36.2%)

3 11 (7.5%) 48 (7.4%)

4 0 (0.0%) 6 (0.9%)

Missing/Coach 4 (2.7%) 21 (3.2%) Total Number of Previous Concussions Among Children

0 115 (78.2%) 336 (51.8%)

1 18 (12.2%) 157 (24.2%)

2 7 (4.8%) 88 (13.6%)

3 3 (2.0%) 32 (4.9%)

4 1 (0.7%) 14 (2.2%)

5 1 (0.7%) 7 (1.1%)

6 0 (0.0%) 1 (0.2%)

>6 0 (0.0%) 2 (0.3%)

Missing/Coach 2 (1.4%) 12 (1.8%)

Medical or first aid certification No 105 (71.4%) 376 (57.9%)

Yes 41 (27.9%) 263 (40.5%)

Missing 1 (0.7%) 10 (1.5%)

Completed the Hockey Canada Safety Program No 91 (61.9%) 301 (46.4%)

Yes 30 (20.4%) 237 (36.5%)

I don't know 17 (11.6%) 87 (13.4%)

Missing 9 (6.1%) 24 (3.7%)

5.3.1 Sources of concussion information Table 5.2 describes where hockey parents and coaches obtain information about concussion and how helpful they find the information. The top sources of concussion information reported by parents and coaches included the Internet (64.7%), healthcare professionals (63.6%), and the hockey association (50.6%). Other sources described by participants included the associations of different sports, personal experience with concussion, the concussion study, professional associations, radio, the university, apps and, work. The most helpful resources included healthcare professionals, workshops/ coaching clinics and research articles. Parents and coaches who had received concussion information in the last year reported receiving concussion information from a median of 4 sources ranging between 1-10 sources on the list. Out of 738 respondents, 149 (79.8%) reported being interested in being educated about concussion. Figure 5.2 illustrates where parents and coaches would like to get their concussion information from.

Figure 5.2 Frequency of self-report preferred sources for concussion education by parents and coaches

Figure 4 Figure 5.2 Frequency of self-report preferred sources for concussion education by parents and coaches

327 Healthcare Professionals 166 493

306 Medical Doctor 139 445

288 The Hockey Association 134 422 No Coaching 87 Experience Online Workshops 64 (n=536) 151 Coaching 70 Experience In Person Training 53 (n=260) 123

9 Other 9 18

0 100 200 300 400 500 600

90 Table 5.2. The source and helpfulness of concussion information obtained by parents and coaches of youth ice hockey players

Table 13 5.2 The source and helpfulness of concussion information obtained by parents and coaches of youth ice hockey players

Do you get information from the following places? Degree of helpfulness Not Extremely Source of information n No Yes helpful A little Somewhat Very helpful Missing 377 386 2 35 158 139 44 8 Hockey Association 763 (49.4%) (50.6%) (0.5%) (9.1%) (40.9%) (36.0%) (11.4%) (2.1%) Workshops/Coaching 556 201 1 17 66 77 35 5 Clinics 757 (73.4%) (26.6%) (0.5%) (8.5%) (32.8%) (38.3%) (17.4%) (2.5%) 419 340 19 126 146 42 7 Research Articles 759 (55.2%) (44.8%) (0.0%) (5.6%) (37.1%) (42.9%) (12.4%) (2.1%) 464 293 4 68 155 51 12 3 TV 757 (61.3%) (38.7%) (1.4%) (23.2%) (52.9%) (17.4%) (4.1%) (1.0%) 507 252 5 52 135 46 10 4 Newspapers 759 (66.8%) (33.2%) (2.0%) (20.6%) (53.6%) (18.3%) (4.0%) (1.6%) 610 143 5 23 69 31 10 5 Social (Facebook, twitter) 753 (81.0%) (19.0%) (3.5%) (16.1%) (48.3%) (21.7%) (7.0%) (3.5%) 593 163 2 22 87 39 11 2 Magazines 756 (78.4%) (21.6%) (1.2%) (13.5%) (53.4%) (23.9%) (6.7%) (1.2%) 268 491 36 211 179 54 11 Internet 759 (35.3%) (64.7%) (0.0%) (7.3%) (43.0%) (36.5%) (11.0%) (2.2%) 277 485 13 82 217 163 10 Health Care Professionals 762 (36.4%) (63.6%) (0.0%) (2.7%) (16.9%) (44.7%) (33.6%) (2.1%) 428 333 6 57 159 82 21 8 Other Parents 761 (56.2%) (43.8%) (1.8%) (17.1%) (47.7%) (24.6%) (6.3%) (2.4%) 654 81 2 17 24 31 7 Other 735 (89.0%) (11.0%) (0.0%) (2.5%) (21.0%) (29.6%) (38.3%) (8.6%)

91 5.3.2 Parent and Coach Concussion Knowledge Table 5.3 summarizes the proportion of parents and coaches who correctly responded to knowledge questions stratified by whether or not they have received concussion education. The mean knowledge score for all participants was 25.85/32. Overall, participants scored lowest on items related to management and return to play as well as the distinction between concussion symptoms and specific distractors (e.g., fever, panic attacks, weight gain, reduced breathing rate). Compared to parents and coaches who did not receive concussion education a larger proportion of parents and coaches were able to correctly identify distractor symptoms including arthritis (85.7% versus 78.9%) excessive studying (82.0% versus 69.4%). Participants who received concussion education were also more likely to have heard of the terms “graduated return to play protocol” or “stepwise return to play” (58.6% versus 27.2%), recognize an athlete should not return to play while experiencing symptoms (84.0% versus 72.6%) and identify that postconcussion symptoms can be delayed for hours or days (90.3% versus 81.3%). The average knowledge score for participants with coaching experience was 26.45/32 whereas the average knowledge score for participants without coaching experience was 25.57/32. Based on the multivariable regression analysis adjusting for coaching experience, previous history of a child sustaining one or more concussions, first aid experience, and cluster by team, receiving concussion education is associated with a mean score increase of 1.36 (95%CI: 0.68 to 2.03), p<0.0001 in the knowledge score. Having coaching experience [coefficient=0.65 (95%CI; 0.17 to 1.13, p=0.008] and first aid experience [coefficient= 0.69 (95%CI; 0.26-1.12), p=0.002] was also associated with a slight significant increase in the mean knowledge score in the model.

92 Table 5.3. Parent and coach knowledge by exposure to previous education Table 14 5.3 Parent and coach knowledge by exposure to previous education No Previous Previous Concussion Concussion Total Total Education Education Sample n Correct n Correct n Correct n (%) (%) (%) Definition 142 622 764 A concussion is a brain injury (T) 785 (97.9%) (97.2%) (97.3%) Understanding the risk of concussion There is a higher risk of long term problems if someone has a 139 625 764 second concussion before recovering from the first one. (T) 795 (94.6%) (96.5%) (96.1%) People who have had one concussion are more likely to have 124 522 646 another concussion. (T) 789 (84.9%) (81.2%) (81.9%) There are few risks to long-term health and well-being from 116 537 653 multiple concussions. (F) 793 (78.9%) (83.1%) (82.3%) Misconceptions Sometimes a second concussion can help a person remember things 123 564 687 that were forgotten after the first concussion. (F) 794 (83.7%) (87.2%) (86.5%) 139 639 778 There are helmets that prevent all concussions. (F) 796 (94.6%) (98.5%) (97.7%) Recognition 124 596 720 Concussions can sometimes lead to emotional problems. (T) 795 (84.4%) (92.0%) (90.6%) In order to be diagnosed with a concussion, you have to be knocked 144 645 789 out. (F) 795 (98.0%) (99.5%) (99.2%) 124 578 702 A concussion can only occur if there is a direct hit to the head (F) 795 (84.4%) (89.2%) (88.3%) Signs and Symptoms 119 582 701 Hives (N) 791 (81.5%) (90.2%) (88.6%) 146 642 788 Headache (Y) 793 (99.3%) (99.4%) (99.4%) 75 334 409 Fever (N) 788 (51.0%) (52.1%) (51.9%) 116 553 669 Arthritis (N) 792 (78.9%) (85.7%) (84.5%) 142 642 784 Sensitivity to Light (Y) 793 (96.6%) (99.4%) (98.9%) 144 644 788 Difficulty Remembering (Y) 792 (98.6%) (99.7%) (99.5%) 33 149 182 Panic Attacks (N) 790 (22.4%) (23.2%) (23.0%) 138 619 757 Feeling Tired (Y) 790 (93.9%) (96.3%) (95.8%) 139 638 777 Feeling in a Fog (Y) 790 (94.6%) (99.2%) (98.4%) 95 455 550 Weight Gain (N) 790 (64.6%) (70.8%) (69.6%) 134 595 729 Feeling Slowed Down (Y) 790 (91.2%) (92.5%) (92.3%) 47 218 265 Reduced Breathing Rate (N) 788 (32.0%) (34.0%) (33.6%) 102 529 631 Excessive Studying (N) 792 (69.4%) (82.0%) (79.7%) 144 641 785 Difficulty Concentrating (Y) 792 (98.0%) (99.4%) (99.1%) 144 646 790 Dizziness (Y) 793 (98.0%) (100.0%) (99.6%) 115 547 662 Hair Loss (N) 791 (78.2%) (84.9%) (83.7%)

93 Table 5.3. Parent and coach knowledge by exposure to previous education (Continued)

No Previous Previous Concussion Concussion Total Total Education Education Sample n Correct n Correct n Correct n (%) (% ) (% ) Response After a collision, body check, or fall your child/player starts 135 627 762 vomiting repeatedly. (ED) 793 (92.5%) (96.9%) (96.1%) After a collision, body check, or fall your child/player has a 76 361 437 headache that continues to get worse. (ED) 791 (52.1%) (56.0%) (55.2%) Immediately after a collision, body check, or fall your child/player immediately complains of a headache and dizziness but starts to 104 500 604 feel better by the end of the game. (NU) 791 (71.7%) (77.4%) (76.4%) Management and Return to Play Younger players (under the age of 18) typically take longer to 29 132 161 recover from a concussion than adults. (T) 793 (19.7%) (20.4%) (20.3%) 120 585 705 Post-concussion symptoms can be delayed for hours or days. (T) 795 (81.6%) (90.3%) (88.7%) An athlete can return to play while experiencing symptoms of a concussion if directed to do so by an athletic trainer or a physician. 106 544 650 (F) 794 (72.6%) (84.0%) (81.9%) Have you heard of the term “graduated return to play protocol” or 40 378 418 "stepwise return to play" for concussion? (Y) 792 (27.2%) (58.6%) (52.8%) 26.15 Total Score, Mean (SD)1 741 24.57 (3.89) (2.95) 25.85 (3.20) Abbreviations: T-True; F-False; Y-Yes; N-No; DN-Do nothing; NU-Non-Urgent, book an appointment with a physician; ED-Go to the emergency department 1There were 139/741 participants with no history of concussion education and 602/741 participants with a history of concussion education Items that are in bold had greater than a 5% difference in the proportion of correct responses between those who had received concussion education and those that had not received concussion education

5.3.3 Parent and coach beliefs under the scope of the Health Action Process Approach Only 14/134 coaches who responded to the belief and behaviour sections of the questionnaire had not previously received concussion education. The majority of these participants (12/14) were assistant coaches. Participant characteristics of this sample are presented in Table 5.4. Summary statistics for the constructs in the Health Action Process Approach stratified by exposure to previous education are presented in Table 5.5. The HAPA constructs were variable and not normally distributed and there was a limited number of participants in each group. Therefore non-parametric statistics were performed using a Wilcoxon rank sum test. There were no significant differences found between

94 those who had received concussion education in the last year and those who had not (see table 5.5 for statistics).

Table 5.4 Characteristics of coaches who completed the questionnaire section on coach beliefs Table 15 5.4 Characteristics of coaches who completed the questionnaire section on coach beliefs

No Concussion Received Concussion Education (n=14) Education (n=120) Coach Type Head Coach 2 (14.3%) 36 (30.0%) Assistant Coach 12 (85.7%) 79 (65.8%) Missing 0 (0.0%) 5 (4.2%) Age, mean (SD) 44.3 (8.59) 45.38 (7.87) Missing 4 (28.6%) 16 (13.3%) Coaching Age Group* Tyke 3 (21.4%) 20 (16.7%) Timbit 7 (50.0%) 70 (58.3%) Novice 11 (78.6%) 93 (77.5%) Atom 11 (78.6%) 99 (82.5%) Pee Wee 12 (85.7%) 102 (85.0%) Bantam 12 (85.7%) 100 (83.3%) Midget 3 (21.4%) 43 (35.8%) Junior 0 (0.0%) 6 (5.0%) Varsity 0 (0.0%) 2 (1.7%) Years of Coaching Experience 0 to <5 years 3 (21.4%) 22 (18.3%) 5 to <10 years 6 (42.9%) 53 (44.2%) >=10 years 4 (28.6%) 38 (31.7%) Missing 1 (7.1%) 7 (5.8%) Access to medical professionals on the bench* No Access 7 (50.0%) 65 (54.2%) Athletic Therapist 1 (7.1%) 14 (11.7%) Physiotherapist 1 (7.1%) 1 (0.8%) Doctor 0 (0.0%) 7 (5.8%) Paramedic 2 (14.3%) 11 (9.2%) Other § 3 (21.4%) 23 (19.2%) *Participants could select more than one response §Other participants listed included: chiropractor, fireman, first aid person, nurse, respiration therapist

95 Table 5.5 Summary statistics of the Health Action Process Approach constructs related to parent and coach concussion behaviour management Table 16 5.5 Summary statistics of the Health Action Process Approach constructs related to parent and coach concussion behaviour management

Provided No concussion concussion information in the information in the Outcome last year last year Wilcoxon rank-sum test Number of Median Median Items n (IQR) n (IQR) z p HAPA Constructs related to parents taking their child in for physician assessment and clearance 5.50 5.67 Risk Perception 6 143 (3.33-7) 629 (3.17-7) -0.592 0.5542 6.19 6.13 Outcome Expectancies 8 140 (4.00-7) 624 (2.50-7) 0.713 0.4756 6.25 6.50 Action Self-Efficacy 2 144 (3.50-7) 637 (1.00-7) -1.291 0.1966 6.50 7.00 Intention 2 146 (4.00-7) 637 (1.00-7) -0.003 0.9979 Maintenance Self- 7.00 6.67 Efficacy 3 145 (4.00-7) 638 (1.00-7) 0.213 0.8311 Recovery Self- 7.00 7.00 Efficacy 2 143 (2.00-7) 613 (1.00-7) 0.563 0.5733 5.50 6.00 Planning 2 138 (1.00-7) 628 (1.00-7) -1.583 0.1135 HAPA constructs related to coaches removing a player from a game or practice due to a suspected concussion 5.57 5.71 Risk Perception 14 (5.29-5.86) 118 (4.29-6.71) -0.538 0.5908 6.08 6.00 Outcome Expectancies 6 14 (5.50-6.67) 117 (4.00-7) 0.661 0.5085 6.00 6.33 Action Self-Efficacy 3 14 (5.33-6.33) 120 (4.00-7) -1.140 0.2541 6.00 7.00 Intention 2 14 (6.00-7) 118 (4.00-7) -0.948 0.3432 Maintenance Self- 6.67 7.00 Efficacy 3 14 (6.00-7) 120 (4.00-7) -0.808 0.4192 Recovery Self- 7.00 6.50 Efficacy 2 13 (6.00-7) 120 (4.50-7) 0.709 0.4783 4.00 4.00 Planning 2 13 (1.00-7) 118 (1.00-7) -0.446 0.6556

5.3.4 Self-reported Parent and Coach Behaviour There were 93/786 parents who reported having a child who sustained at least one suspected concussion over the last hockey season (88 participants reported 1 suspected concussion and 5 participants reported having 2 concussions). Of the parents who reported a child with a suspected concussion, 75/93 (80.6%) participants reported seeing a physician for diagnosis and 71/93 (76.3%) reported seeing a physician for clearance to

96 return to play for all suspected concussions. A greater proportion of individuals who reported receiving concussion education also saw a physician for assessment [73/85 (85.9%)] and clearance [69/85 (81.2%)] when compared to those who reported not having received concussion education (2/8, 25% for both assessment and clearance). Parents who received concussion education were also more likely to educate their own child about concussion (422/610, 69.2%) than whose had not received education (48/139, 34.5%). Participants who believed they had the resources to educate their child about concussion (458/732, 62.7%) were more likely to educate their child than those who felt they did not (340/458 versus 118/274, chi-squared = 80.23, p<0.0001). Of the 132 coaches who completed the section on coach behaviour, 71 (53.8%) reported having suspected a concussion in the last season. Only 4/70 (6%) coaches reported not removing an athlete when a concussion was suspected. However, 12/68 (17.6%) coaches reported that at least one player continued to play for a short time following a suspected concussion mechanism before being removed.

5.4 Discussion This is the first study to examine the effect of concussion education on knowledge and beliefs related to concussion management under the scope of the Health Action Process Approach in a Canadian sample. It is also one of the few studies that examine the effect of education on parent beliefs in addition to the effect on knowledge. The finding that previous education is related to slight changes in knowledge is consistent with the previous studies in parents and coaches.247,292–296 For example, Hecimovich et al285 reported that exposure to previous concussion training had a significant effect on Australian Rules Football parent knowledge of signs and symptoms of concussion (p=0.001) and true or false questions on a combination of concussion management and return to play questions (p=0.001). Kroshus et al292 reported similar increases in coach knowledge associated with previous concussion education in a sample of collegiate sport coaches. Overall concussion knowledge of signs and symptoms appears to be increasing in youth parents and coaches. For example, approximately 90% of participants in this sample correctly identified that emotional symptoms can be due to concussion. Conversely, a previous study in youth football parents in 2011 reported only

97 50% of participants correctly identified emotional symptoms as related to concussion.296 Given this was not different between those who had education and those that have not, this may be the result of stories in the media highlighting the association between concussions and depression.297 On the other hand, the participants in this study scored poorly on knowledge items related to response and management. This may have important implications given that 19% of parents still choose not to see a physician regarding management and may not be aware of the graduated return to play protocol. The two previous studies that examined the effect of concussion education using a behaviour change framework in parents293 and coaches247 identified significant effects on behavioural intention and self-efficacy. However, the educational intervention used in these studies was designed and informed by a behaviour change theory (health beliefs model) whereas the education in this study could have taken any form. This is a key difference between the studies that may provide some evidence towards the benefits of incorporating behaviour change theory in both the design of the educational tool and the evaluation.

5.5 Limitations The participants in this study were not randomly selected from the population but rather recruited from within another study. While this procedure allowed for a large number of parents to be included in the study, it may also have resulted in greater knowledge and more positive beliefs. Furthermore, parents in this study have expedited direct access to the sport medicine physicians at the university, which may have resulted in higher ratings for intention and planning related to seeing a physician for the parents in this sample. The low response rate of participants who completed the questionnaire relative to the full sample of participants in the prospective study was primarily due to the challenges associated with data collection at multiple sites and because many of the parents of youth ice hockey players above Bantam age group do not take their child to games and practices and were not available at the time of testing. This may have also contributed to a sample with greater knowledge and more positive beliefs because parents

98 who completed the questionnaires may represent a sample with a greater interest in concussion. This is the first study to try and measure the Health Action Process Approach constructs in a youth ice hockey sample to understand concussion management behaviours. Therefore, there were no previous validated questionnaires that could be used. While there were processes in place to validate the questionnaire using experts in the area, pilot testing and qualitative interviews, there may still be a risk of measurement bias. Specifically, despite good internal reliability in a pilot study of the questionnaire, some of the constructs in the HAPA model had poor internal reliability in this sample. Future steps towards questionnaire development including structural equation modeling may be necessary to better understand the concerns related to the internal reliability of the constructs. Furthermore, many of the participants rated the highest value for all items on the maintenance self-efficacy, intention, action self-efficacy and outcome expectancies scales. While this may indeed represent higher ratings for these beliefs, it may also represent a lack of exposure or recognition of the experience (see Chapter 3 of this dissertation). There might also be concerns about the validation of the questionnaires used to inform this questionnaire specifically with respect to the selection of distractor items. For example, only 23% of parents and coaches correctly identified panic attacks as not a symptom of concussion. Increased anxiety/nervousness following concussion may have lead individuals to believe panic attacks are a symptom. Consistent with other questionnaires designed to measure beliefs, this study assumes the participants answered the questionnaires truthfully and without outside influence.

Another limitation of the study is the inability to adjust for type, description, or timing of concussion education received. While quantifying the exposure as educated or not reflects the nature of blanket educational policies that allow individual associations to select their education format, prospective research is needed to better control both the short-term and long-term effects of education using behaviour change paradigms. This is especially important given the type of education can affect education outcomes. For example, Rivera et al.291 found that in person training and written material may be more effective than video's or quiz's at increasing a coaches’ likelihood of being aware a concussion occurred. Finally, given the retrospective nature of the data, there is always a

99 risk of misclassification bias where the participant does not remember receiving concussion education. The distribution of the data collected on parent beliefs and the limited number of coaches who did not receive education made it challenging to control for confounders in the assessment of the association of previous education on parent and coach beliefs in a multivariable model. Factors such as age, parent type, coaching experience, and personal concussion history could result in differences in the association. It is also possible that the limited sample of coaches without concussion education may have resulted in a type II error. Future research is needed to address this limitation in a larger sample. Only a limited portion of the sample had the opportunity to perform the target behaviours related to concussion management in the previous season and there was no way to determine if the behaviour occurred prior to or after the exposure to education using this study design. While the hypothesis that education typically occurs at the beginning of a season is reasonable, it is important to note the ability to examine the effect of previous education on these behaviours is challenging due to both the limited cases and the cross-sectional nature of the data. Using a longitudinal design controlling for participant factors would also be recommended both to address concerns around controlling for confounding factors as well as concerns due to temporality.

5.6 Conclusions The results from this paper suggest that previous exposure to education may be associated with increases in parent and coach knowledge, but is not associated with changes in parent or coach beliefs. Concussion knowledge is improving within concussion parents and coaches. However, while many parents and coaches report appropriate behaviour related to concussion management there are still incidences where the appropriate action is not taken despite receiving concussion education. Parents who receive concussion education are more likely to try and educate their children about concussion than those who do not received concussion education which may be a valuable opportunity to address the concerns around player reporting. However, more research is needed to examine the accuracy of the information provided by parents and how different ways of providing it may affect player beliefs. This project informs the

100 understanding of how previous education affects concussion knowledge and the beliefs surrounding behaviour management in parents and coaches using the Health Action Process Approach. Future work should focus on the continual development of the tools to identify the potential barriers and motivations related to concussion management so that we are better able to evaluate the effectiveness of interventions. More research examining the effects of different types of education on the beliefs and behaviours related to concussion management using a longitudinal study design is also needed.

101

Chapter 6: The Risk of Injury Associated with Body Checking among Pee Wee Ice Hockey Players: An evaluation of Hockey Canada’s national body checking policy change

Black AM, Hagel BE, Palacios-Derflingher L, Schneider KJ, Emery CA. The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada’s national body checking policy change. Br J Sports Med. 2017:bjsports-2016-097392. doi:10.1136/bjsports-2016-097392.

102 6.1 Introduction Youth ice hockey is a popular winter sport in North America with approximately half a million youth in Canada and the United States registered annually.98,99 While hockey has the benefits of many team sports including assisting with physical, motor and social development, it also carries a high risk of injury.3,4,6,10,11 One of the most common injuries resulting in time loss in youth hockey is concussion, accounting for 18 to 66% of all injuries and raising significant health concerns.5–11 Systematic reviews examining the risk factors for injury and concussion in hockey have identified the tactical strategy of body checking as one of the most consistent risk factors for injury.27,101 Body checking is a defensive technique in which a player makes contact with another player moving in the opposite direction in an attempt to remove the player from the puck; it is often heralded for bringing excitement to the game at the professional level.298,299 While advocates of body checking believe that it is fundamental to the game, the age and level at which checking is introduced remains contentious.5 Several studies comparing provincial policy identified a 2 to 4-fold increased risk of injury and concussion among Pee Wee players in leagues that introduce body checking at the Pee Wee age group (11-12 years) compared with leagues that introduce body checking later at both elite and non-elite levels of play.6,10 The strong research evidence along with meetings between researchers and members of local and national hockey associations contributed to USA Hockey’s decision to delay the introduction of body checking until Bantam (13-14 years) in 2012.300,301 Hockey Canada introduced a similar policy change in 2013.302 Previous reports examining the effect of body checking policy changes in Pee Wee using prospective community surveillance data have relied on comparing injury rates between provinces.6,10 The objective of this study is to determine if the risk of injury, including concussion, differs for Pee Wee (11-12 years) ice hockey players in the season following a national policy change disallowing body checking (2013-14) compared with a season when body checking was allowed (2011-12) in the same province. A secondary objective was to examine how mechanisms of injury differ between a cohort (2011-12) where body checking was permitted and a cohort when it was not permitted (2013-14).

103 6.2 Methods

6.2.1 Design, Sample, and Data Acquisition A historical cohort study was conducted using data from two prospective cohort studies examining injury rates and mechanisms of injury in youth ice hockey.6 The first cohort included injury data collected from Pee Wee teams in all divisions of play in Calgary during the 2011-12 season when body checking was permitted. The second cohort included data on Pee Wee teams and individual players from all divisions of play in Calgary collected during the 2013-14 season when body checking was disallowed. An inclusive sampling strategy was used for both cohorts; all Pee Wee hockey associations affiliated with Hockey Calgary were invited to participate in the study. Recruitment started at the association level. If the association agreed to allow researchers to contact team managers/coaches, the teams were invited to participate. Teams were included if they identified a parent volunteer (team designate) who could report weekly participation and initiate an injury report form. Only male teams were included in this analysis because female teams have never been permitted to body check. However, females playing on male teams were included. Teams are entitled to a maximum of 19 players though the number per team enrolled in the study varied depending on individual player assent and parent/guardian consent.299 In the 2013-14 cohort, individuals on teams that did not have a team designate could also be included if they agreed to track their weekly participation and report injuries. Players who were concussed at cohort time zero were excluded. Data collection procedures were based on a previously validated injury surveillance system described in detail in previous studies.6,9–11,303 Players completed a preseason baseline questionnaire (PBQ) to collect information on participant characteristics and potential risk factors for injury [sex, height, weight, year of play, division of play, prior injury experience (self- reported lifetime concussion history and other injury within the last year), and attitude towards body checking304] (See Appendix H). Trained research assistants also administered the Sport Concussion Assessment Tool21,305(most current version 2 or 3 depending on year) to all participants. Throughout the season, team or individual designates recorded individual level weekly exposure to hockey sessions and injuries (See Appendix I). Injuries were defined as any incident

104 occurring during hockey that required medical attention, resulted in the inability to complete the session of activity and/or the inability to participate in sporting activities for one day. Data regarding how the injury occurred, date of injury, whether the injury occurred in game or practice, mechanisms, injury location, injury type and time loss from sport were reported on an Injury Report Form (IRF) and validated by a study Certified Athletic Therapist or Physiotherapist (See Appendix J). Injury mechanism categories included: 1.Body checking, 2.Other Intentional Player Contact (Elbowing, Slashing, Tripping, Roughing, Cross-checking, Head Contact) 3.Incidental (unintentional) Contact with another player or their equipment, 4.Contact with the environment (puck, board, net), 5 No contact, or 6.Unknown. In cases where head contact or contact with the environment occurred as a result of a body check, the injury mechanism was coded as body checking. Injuries resulting in greater than 7 days time loss from sport were defined as severe injuries and referred to the study therapist for assessment. Any player with a suspected concussion was referred to a study sport medicine physician trained to diagnose concussion based on the most current consensus guidelines on concussion in sport.21,305 If the participant did not visit the study physician, a suspected concussion was identified by the study therapist if the IRF indicated a mechanism that involved a force to the head or body resulting in symptoms of concussion in accordance with the most current consensus guidelines.21,305 In order to remain consistent with previous studies examining policy changes in youth hockey, concussions resulting in greater than 10 days time loss were also identified.6,9,10,306 Due to the nature of the historical cohort design, no a priori sample size calculation was performed. However, based on previous sample size calculations to investigate differences in injury rate associated with body checking, a sample size of 30 teams per cohort was determined as required to identify a difference between the two cohorts [powered based on an incidence rate ratio (IRR)=3.00 (concussion rate=1.47/1000 player-hours in Alberta, adjusting for cluster and anticipated 10% drop- out rate (α=0.05, β=0.20)].6

105 6.2.2 Statistical Analysis STATA version 14 was used to perform all statistical analyses.307 Baseline characteristics of participants were stratified by those who sustained at least one game- related injury throughout the season and described by cohort. Game related injury rates and incidence rate ratios (IRR) with 95% confidence intervals (CI) were estimated based on Poisson regression adjusted for cluster by team with player exposure game-hours used as an offset. Models for primary injury outcomes (all game injury and game concussion) were adjusted for previously identified risk factors for injury: year of play (first or second year of Pee Wee based on birth year), weight, previous injury within the last year or any previous concussion, level of play [elite divisions of play 1-3 (top 30%) or non-elite divisions of play 4-12 (lower 70%)], position, and attitudes towards body checking [dichotomized at 75th percentile (36/55 items on a body-checking questionnaire) based on a previous sample of 2154 Pee Wee players ].6,10 Sex was not considered a covariate because of low numbers. The primary adjusted risk factor analysis comparing cohorts was a complete case analysis whereby participants with missing covariate data were excluded. Due to low event rates of secondary outcomes, severe injuries and concussions resulting in greater than 10 days time loss, univariate models were reported (adjusting for cluster by team and offset by player-hours). The absolute risk reduction (ARR) was calculated based on the unadjusted injury rates between cohorts. The total population estimates for number of injuries and concussions that were prevented over the course of a season were calculated using the ARR, average game-hours, and Pee Wee registration numbers in Alberta and across Canada provided in Hockey Canada’s 2015 annual report.1 A sensitivity analysis was conducted to determine the effect of missing data in the risk factor analysis using multiple chain imputation.308 Logistic regression of each covariate coded as missing or non-missing was used to assess the assumption of data missing at random. Missing weekly exposure hours were replaced for each player with values imputed based on average team level data or level of play related data if the whole team was missing. An additional sensitivity analysis was conducted repeating the primary risk factor analysis with only physician-diagnosed concussion as an outcome. IRRs with 95% CIs associated with differences between specific mechanisms of injury between the two cohorts were estimated using univariate Poisson regression adjusted for cluster by

106 team with player exposure game-hours used as an offset. Negative binomial regression did not lead to different results. Statistical significance was based on an α level of 5%.

6.2.3 Ethics Approval

Ethics approval for both the 2011-12 and 2013-14 cohorts was obtained from the Conjoint Health Research Ethics Board at the University of Calgary (Ethics ID# 20252 and 14-0348 respectively). All player participants and parents provided written consent to participate.

6.3 Results In 2011-12, 59 of 115 teams (51.3%) approached participated in the study (n=883). In 2013-14, 62 of 127 teams (48.8%) approached participated and 13 individuals from 11 teams completed data collection individually and were included in the study (n=618). The primary reason for a team’s refusal to participate was the inability to identify a team designate to collect data. The number of participants enrolled per team ranged between 5 and 19 (median=16) in 2011-12 and between 2 and 17 (median=11) in 2013-14. Participant characteristics are displayed in Table 6.1. Baseline characteristics were similar between the two cohorts, with the exception of attitudes towards body checking and previous concussion. Players in the body checking cohort reported a stronger preference towards body checking (mean score= 36.99 vs. 29.49 for injured participants and 36.03 vs. 30.23 for non-injured participants out of 55). A greater proportion of participants in the 2013-14 cohort reported having previous concussion(s) when compared with the 2011-12 cohort.

107 Table 6.1: Baseline Characteristics Comparing Pee Wee (11-12 Years) Hockey Players in 2011-12 and 2013-14

Table 17 6.1 Baseline characteristics comparing Pee Wee (11-12 years) hockey players in the 2011-12 and 2013-2014

Injured Not Injured 2011-12 2013-14 2011-12 2013-14 Baseline Characteristic n=142 n=47 n=741 n=571 Sex, No. (%) Male 136 (95.77) 45 (95.74) 698 (94.20) 551 (96.50) Female 3 (2.11) 2 (4.26) 32 (4.32) 20 (3.50) Missing data 3 (2.11) 0 11 (1.48) 0 Height, mean (SD), cm 151.43 (8.70) 151.25 (9.07) 152.14 (9.10) 151.67 (8.43) Missing data, No. (%) 31 (21.83) 1 (2.13) 182 (24.56) 13 (2.28) Weight, mean(SD), kg 42.82 (8.44) 42.08 (9.15) 43.38 (8.99) 42.34 (9.03) Missing data, No. (%) 33 (23.24) 1 (2.13) 163 (22.00) 10 (1.75) Year of play, No. (%) First 88 (61.97) 24 (51.06) 364 (49.12) 308 (53.94) Second 53 (37.32) 23 (48.94) 370 (49.93) 263 (46.06) Missing data 1 (0.70) 0 7 (0.94) 0 Level of play, No. (%) Elite (div 1-3, top 30%) 51 (35.92) 14 (29.79) 243 (32.79) 183 (32.05) Non-Elite (div 4-12, lower 70%) 91 (64.08) 33 (70.21) 498 (67.21) 386 (67.60) Missing data, 0 0 0 2 (0.35) Position, No. (%) Forward 81 (57.04) 29 (61.70) 399 (53.85) 314 (54.99) Defense 49 (34.51) 15 (31.91) 224 (30.23) 181 (31.70) Goalie 5 (3.52) 1 (2.13) 89 (12.01) 57 (9.98) Missing data 7 (4.93) 2 (4.26) 29 (3.91) 19 (3.33) Previous injury†, No. (%) No 114 (80.28) 35 (74.47) 641 (86.50) 461 (80.74) Yes 22 (15.49) 12 (25.53) 83 (11.20) 101 (17.69) Missing data 6 (4.23) 0 17 (2.29) 9 (1.58) Previous concussion, No. (%) No 88 (61.97) 28 (59.57) 605 (81.65) 396 (69.35) Yes 53 (37.32) 19 (40.43) 130 (17.54) 175 (30.65) Missing data 1 (0.70) 0 6 (0.81) 0 Attitude toward body checking total score, mean (SD) score/55 items‡ 36.99 (6.50) 29.49 (7.27) 36.03 (5.92) 30.23 (6.61) Missing data, No. (%) 11 (7.75) 4 (8.51) 45 (6.07) 69 (12.08) †Participants with previous injuries had a self-reported history of one or more injuries over the last year that required medical attention or resulted in time loss from activity. Previous concussions were not included in the measurement of previous injuries in this table. ‡ High scores on the body checking questionnaire suggests a stronger preference to body check.

108 6.3.1 Game Injury Rates Table 6.2 summarizes game outcome measures stratified by cohort. There were a total of 163 game injuries (104 concussions) reported in 2011-12 and 48 game injuries (25 concussions) in 2013-14. In 2011-12, 124 players had one injury, 15 players had two injuries and three players had three injuries. In 2013-14, forty-six players had one injury and one player had two injuries. Injuries that met injury definition included: cuts, bruises, joint swelling, ligament sprains, fractures, muscle strains, tendinitis, dislocations, and concussions.

109 Table 6.2: Summary of Game-Related Outcome Variables for Pee Wee Ice Hockey Injuries in Calgary (2011-12 and 2013-14)

Table 18 6.2 Summary of Game-Related Outcome Variables for Pee Wee ice Hockey Injuries in Calgary

Injury Severe Injury Concussion Concussion (time loss >10 days) Outcome 2011-12 2013-14 2011-12 2013-14 2011-12 2013-14 2011-12 2013-14 No. players 883 618 883 618 883 618 883 618 No. of injuries or concussions 163 48 71 17 104 25 42 14 Athlete participation, h 37273.87 22259.08 37273.87 22259.08 37273.87 22259.08 37273.87 22259.08 Injury rate, injuries per 1000 player-hours (95%CI)† 4.37 2.16 1.90 0.76 2.79 1.12 1.13 0.63 (3.59, 5.33) (1.56, 2.99) (1.48, 2.44) (0.48, 1.23) (2.28, 3.41) (0.75, 1.69) (0.83, 1.53) (0.38, 1.04) Incidence rate ratio 1 1 1 (unadjusted for covariates) [Reference] 0.49 [Reference] 0.40 [Reference] 0.40 1 [Reference] 0.56 (0.34, 0.72) (0.24, 0.68) (0.26, 0.63) (0.31, 1.01) Absolute risk reduction associated with removal of checking, injuries per 1000 player-hours (95%CI) 2.22 1.14 1.67 0.50 (1.31, 3.12) (0.57, 1.71) (0.97, 2.36) (0.02, 0.97) Number of Injuries saved in one 772 396 581 season in Alberta (95%CI)‡ (456, 1085) (198, 595) (337, 821) 174 (7, 337) 6388 3281 4806 Number of Injuries saved in one (3770, (1640, (2791, season in Canada (95%CI)¶ 8978) 4921) 6791) 1439 (58, 2791) †IRRs based on Poisson regression analysis offset for exposure-hours, adjusted for clustering by team, unadjusted for covariates. ‡The population of Pee Wee players from Alberta is 8768. The average game-hours is 39.66 per Pee Wee player. The number of injuries saved is calculated using Alberta population participation and the Absolute Risk Reduction. The number of injuries and confidence limits are rounded to the nearest integer. ¶The population of Pee Wee players from Canada is 72555. The average game-hours from this population is 39.66 per Pee Wee player. The number of injuries saved is calculated using Hockey Canada population participation and the Absolute Risk Reduction. The number of injuries and confidence limits are rounded to the nearest integer.

110 6.3.2 Risk Factors for Injury and Concussion Table 6.3 summarizes the complete case risk factor analysis associated with injury outcomes. Policy disallowing body checking (when adjusted for year of play, previous history of injury or concussion in the last year, level of play, position and attitude towards body checking) was significantly associated with a decreased rate of all injury (IRR=0.50, 95% CI 0.33 to 0.75) and concussion specifically (IRR=0.36, 95% CI 0.22 to 0.58). Previous injury within the last year (IRR=1.70, 95% CI 1.13 to 2.58) and previous concussion (IRR=2.48, 95% CI 1.64 to 3.76) were also identified as independent risk factors for injury and concussion. There were 1134 participants with complete data included in the estimation of the adjusted IRR for injury and 1145 participants for concussion. A sensitivity analysis using multiple chain imputation demonstrated consistent results when comparing the risk associated with policy that removed body checking to policy that permitted it (IRR = 0.47, 95% CI 0.29 to 0.65 for injury and IRR=0.35, 95% CI 0.19 to 0.51 for concussion). Suspected concussions assessed by a physician were 70/104 (67%) in 2011-12 and 20/25 (80%) in 2013-14.A sensitivity analysis of risk factors including only concussions diagnosed by a physician yielded a similar adjusted protective effect estimate (IRR=0.46, 95% CI 0.26 to 0.81).

111 Table 6.3: Risk factor analyses for game-related injury, severe injury, concussion, and concussion with greater than 10 days time loss in Pee Wee ice hockey in Alberta 2011-12 and 2013-14 Table 19 Table 6.3 Risk factor analyses for game-related injury, severe injury, concussion and concussion with greater than 10 days time loss in Alberta 2011-12 and 2013-14

Incidence Rate Ratios (95% CI) Risk Factor Severe Injury‡ Concussion‡ n=number of cases included in univariate analysis All Injury Adjusted† (>7 days time loss) Concussion Adjusted¶ (>10 days time loss) Cohort n=1501 2013-14 0.50 (0.33, 0.75) 0.40 (0.24, 0.68) 0.36 (0.22, 0.58) 0.56 (0.31, 1.01) 2011-12 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] Year of Play n=1493 First 1.39 (0.98, 1.96) 1.21 (0.82, 1.78) 2.63 (1.58, 4.37) 1.83 (1.09, 3.07) Second 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] Player size n=1294 Low weight (<=36.4kg) 1.32 (0.92, 1.90) 1.32 (0.81, 2.13) 1.39 (0.89, 2.15) 1.58 (0.86, 2.91) High weight (>36.4kg) 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] Level of Play n=1499 Upper (div 1-3, top 30%) 1.01 (0.70, 1.45) 1.20 (0.73, 1.96) 0.97 (0.62, 1.54) 1.17 (0.69, 2.01) Lower (div 4-12, lower 70%) 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] Previous Injury (including concussion in the last year) n=1469 Yes 1.70 (1.13, 2.58) 1.92 (1.24, 2.96) NA NA No 1 [Reference] 1 [Reference] NA NA Previous concussion (any concussion, no date limit) n=1494 Yes NA NA 2.48 (1.64, 3.76) 2.66 (1.60, 4.44) No NA NA 1 [Reference] 1 [Reference] Position n=1444 Defense 1.19 (0.86, 1.65) 1.04 (0.67, 1.61) 1.00 (0.66, 1.52) 1.02 (0.55, 1.88) Goalie 0.16 (0.04, 0.65) 0.36 (0.12, 1.06) 0.23 (0.05, 1.04) 0.18 (0.02, 1.35) Forward 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] Attitudes toward body checking n=1372 High (≥36/55) 1.02 (0.70, 1.46) 1.19 (0.74, 1.92) 0.93 (0.62, 1.40) 1.07 (0.61, 1.88) Low (<36/55) 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] Abbreviations: CI, confidence interval, NA, not applicable; div, division. †Incidence rate ratios based on Poisson regression analysis offset for exposure hours and adjusted for clustering by team and covariates (cohort, year of play, previous injury or concussion in the last year, player size, level of play, position of play, and attitudes toward body checking). Complete case analysis included 1134 participants. ‡Incidence rate ratios based on Poisson regression analysis offset for exposure hours and adjusted only for clustering by team, owing to fewer injuries. ¶Incidence rate ratios based on Poisson regression analysis offset for exposure hours and adjusted for clustering by team and covariates (cohort, year of play, previous concussion, player size, level of play, position of play, and attitudes toward body checking). Complete case analysis included 1145 participants.

112 6.3.3 Mechanisms of Injury In 2011-12, body checking was the most common mechanism of injury whereas in 2013-14 the majority of injuries were due to incidental contacts. The injury rate associated with each mechanism of injury is displayed in Figure 6.1. There was a significant difference between the rates of all injuries and concussions due to body checking between 2011-12 and 2013-14 (IRR=0.16, 95% CI 0.08 to 0.32 and IRR=0.21, 95% CI 0.09 to 0.45 respectively).

Figure 6.1 Game-related injury rates by injury mechanism and cohort in Pee Wee ice hockey, 2011–2012 and 2013–2014. Error bars indicate 95% CIs.

Figure 5 6.1 Game-related injury rates by injury mechanism and cohort in Pee Wee ice hockey, 2011-2012 and 2013-2014

113

6.4 Discussion This is the first study to evaluate the protective effect of the 2013 national policy change by Hockey Canada removing body checking from Pee Wee controlling for player exposure-hours. Consistent with provincial comparisons between leagues that permit and do not permit body checking in Pee Wee, this study found a significant reduction in injury and concussion risk associated with the removal of body checking.6,10 Furthermore, a comparison of the mechanisms of injury before and after the rule change suggests there has been a significant reduction in the number of injuries specifically due to body checking. Based on our absolute risk reduction estimates (2.22 injuries per 1000 player-hours and 1.67 concussions per 1000 player-hours), an estimated 772 total injuries and 581 concussions in Alberta and 6388 total injuries and 4806 concussions across Canada are prevented every year as a result of the national policy disallowing body checking in Pee Wee. The overall injury rate observed in this study following the body checking policy change (2.16 injuries per player-game-hours) was slightly higher than Ontario injury rates following the rule change removing body checking from non-elite Pee Wee in 2011-12 (1.60 per 1000 player-game-hours).6 This may be because the current study considered all divisions of play including elite and non-elite while the study in Ontario focused on non- elite players.6 The proportion of suspected concussions assessed by physicians increased in 2013-14 relative to 2011-12 (67% to 80%). These findings may be the result of significant increases in concussion recognition and emphasis on the importance of seeing a physician.309 Increased recognition may also help explain why this study found a larger proportion of Pee Wee players in 2013-14 reporting a history of concussion than Pee Wee players in 2011-12. However, it is also possible that individuals with a previous history of concussion may be more likely to continue playing hockey in a non-checking league. Pee Wee players playing in the 2013-14 season when body checking was no longer permitted displayed a lower preference toward body checking in comparison with the cohort from 2011-12. This result is consistent with a previous study describing attitudes toward body checking in Pee Wee.304 Interestingly, the difference in attitudes

114 toward body checking may become more positive once the players reach Bantam and are allowed to body check. A previous study that reported preference toward body checking in Bantam for players who were exposed to body checking in Pee Wee and those that were not exposed, reported similar body checking attitudes.9 One of the concerns suggested by those who challenge Hockey Canada’s decision to remove body checking from Pee Wee is that the rule change would lead to decreased interest in the sport. However, according to Hockey Canada’s Annual Reports, while registration for male Pee Wee players in Alberta may have experienced a slight decrease in numbers in 2013, (the year where the policy was implemented), registration increased in 2014 and 2015. This suggests an increase in the amount of players choosing to continue playing in Pee Wee (Registration numbers: 8638 in 2012, 8521 in 2013, 8725 in 2014 and 8768 in 2015).1,98,310,311 While this study was conducted using a Pee Wee sample in Alberta, it is expected that the reduction in injury rates after the policy change removing body checking would be generalizable to other hockey associations with Pee Wee teams. There are also important lessons that can be drawn from these results surrounding policy changes that aim to reduce exposure to key risk factors in other sports.

6.5 Limitations This study had a low recruitment rate in both cohorts (2011-12: 51.3% and 2013- 14: 48.8% of teams approached). This may be due to participant and team designate burden in tracking injuries and exposures for the duration of the season. While it is possible that teams included in this study have increased risk perception and therefore may be more likely to report injuries, a clear injury definition minimizes the risk of bias. Further, it is unlikely that this would have differed between the cohorts. Given participant characteristics are self-reported, there is a risk of measurement error whereby a recall bias or lack of awareness of concussion might lead to an under-reporting of previous history of injury or concussion. This could have led to an underestimation of the proportion of individuals with a history of concussion and result in non-differential misclassification bias. Some participants chose not to see a study physician or seek alternative medical assessment. This limits our ability to confirm all suspected cases of concussion.

115 However, the sensitivity analysis including only medically diagnosed concussion suggests a similar reduction in concussion risk associated with the policy change. It is important to recognize that other factors may have changed between 2011-12 and 2013- 14 beyond the introduction of the policy change, though the authors consulted with Hockey Calgary and there were no primary efforts for prevention in this population during this time.

6.6 Conclusions Hockey Canada’s decision to delay body checking until Bantam was effective at reducing the risk of injury and concussion in Pee Wee ice hockey players. It is estimated that implementation of this rule change prevented 772 injuries and 581 concussions in Alberta per year. The process in which policy changes were implemented in youth hockey provides promising approaches for injury and concussion prevention in other sports. Hockey remains a collision sport with many features that can increase an athlete’s risk of injury. There is a need to evaluate the effect of body checking policy in older age groups as well as other potentially modifiable risk factors that can reduce the risk of injury.

116

Chapter 7: Conclusions and Future Directions

117 The overarching aim of this PhD research program was to contribute to the literature and inform best practice regarding prevention and management of concussion in sport with a specific focus on youth ice hockey. The complete elimination of concussions in youth sport using primary prevention strategies is likely unattainable. As such, the role of concussion education as a secondary prevention strategy in youth ice hockey was examined. Education has been identified by government and sport governing bodies as essential to the appropriate management of individuals following concussion and is strongly recommended in numerous concussion management policies.261,312 However, these policies do not specify how education should be provided. Furthermore, there has been some evidence to suggest that certain types of education may only affect knowledge rather than change behaviour. This PhD research program has aimed to address gaps in the literature in several ways. First, while incorporating behaviour change theories into the development and evaluation of injury prevention strategies is recommended, there is a dearth of studies within the context of concussion prevention.313 Therefore, this research program is focused on associations between concussion education and knowledge, beliefs, and behaviours related to the management of concussion under the scope of a behaviour change theory. Second, given that many youth ice hockey players do not have access to medical professionals on the sidelines of their games and practices, this research focused on the knowledge, beliefs and management behaviours of players, coaches and parents. Third, within the context of youth ice hockey, there is limited evidence on the motivators of concussion-related behaviour for parents and coaches. As such, the use of qualitative methodology to inform concussion management for these populations and measurement tool development is considered a valuable addition to the literature and is expected to inform best practice. Finally, specific to the context of youth ice hockey, previous research had identified that policy disallowing body checking could have a preventative effect in reducing concussion risk. As such, the final chapter of this thesis provides evidence for an effective primary concussion prevention strategy in youth ice hockey.

Chapter 2 of this dissertation serves as an introduction to the burden of concussion in all sports; highlighting key limitations of injury surveillance in concussion

118 and posits concussion prevention strategies. Injury surveillance is critical to implementing and evaluating injury prevention strategies but concussion prevention strategies may be difficult to implement due to an evolving definition, lack of an objective gold standard measurement for identification and diagnosis, and challenges in measuring exposure data. For example, the definition of concussion used throughout this document is the one provided by the International Consensus on Concussion in sport group in the 4th concussion statement. However, in the weeks following the submission of this thesis, it is expected that a new definition will be released. Ongoing surveillance is needed to continue evaluating the effectiveness of concussion prevention strategies. Future research should focus on the development of an objective gold standard definition and measurement for concussion identification and diagnosis.

Chapter 3 focuses on the concussion management experience of coaches and parents of youth ice hockey players. There are three main barriers identified that are related to coaches appropriately removing a player with a suspected concussion from play: 1) players concealing or downplaying the severity of their symptoms, 2) difficulty in assessing a concussion when the game continues, and 3) a lack of understanding or recognition that concussion symptoms can be delayed. While coach education may assist with addressing understanding of symptoms, providing resources to assist with coach recognition and changing the culture of reporting are also important considerations not addressed by many education strategies. Chapter 3 also identifies three barriers to parents not taking their child in to see a physician for assessment and clearance as well as several perceived barrier. Barriers that emerged while discussing their experience of concussion and forecasted concussion management strategies included: 1) lack of understanding related to timing, importance, and specificity of signs and symptoms, 2) perceived physician access (e.g., availability, timing), and 3) parents feeling they know their child better than the coach or the physician. It also identified that parents perceive a lack of education as a barrier but what perceived appropriate education refers to can vary from person to person. While education can be used to address beliefs regarding behaviour, it needs to be tailored to those specific barriers. Glang et al.247,293 demonstrated that an educational intervention designed using the tenets of behaviour change theory (Health

119 Belief Model) can influence measures of self-efficacy and behavioural intention in a population of coaches and athletes. However, given that intention does not always result in behaviour change, further examination is needed.

Chapters 4 and 5 evaluate the association between previous concussion education and knowledge beliefs and behaviours related to concussion management in youth ice hockey (parents, players and coaches) under the scope of the Health Action Process Approach. The findings suggest that participants who were provided information on concussion had greater knowledge but did not report any differences in the HAPA constructs designed to predict behaviour change. (See Figures 7.1-7.4) Specifically, very few differences were found related to concussion management beliefs in coaches and parents. While some constructs were close to the maximum positive rating for both groups, the construct related to planning to do the behaviour had the lowest ratings in both parent and coach populations. This finding was consistent with the findings from the qualitative study outcomes in Chapter 3. Specifically, having plans in place regarding how, when and who does a target behaviour is a key construct that distinguishes the HAPA model from the theory of planned behaviour. In Chapter 3, having a team protocol (which relates to planning) that enforces appropriate concussion management was a facilitator to behaviour and in Chapter 5 this construct had the highest potential for improvement. Given that 17.6% of coaches reported at least one player continuing to play before removal as well as the finding that approximately 20% of parents did not consult a physician for assessment and clearance to return to play following all of their child’s suspected concussions, interventions that can target these behaviours are highly recommended.

120 Figure 7.1 Concussion knowledge by previous history of concussion education and participant group

Figure 6 7.1 Concussion knowledge by previous history of concussion education and participant group

27 No Education Education 26

23 Mean Score (/32) (/32) Score Mean 22

21 Players Parents Coaches

Figure 7.2 Constructs of the Health Action Process Approach by previous history of concussion education for players

Figure 7 7.2 Constructs of the Health Action Process Approach by previous history of concussion for players

7 6 No Education 5 Education 4 3 2

Mean Score (SD) Score Mean 1 0

121 Figure 7.3 Constructs of the Health Action Process Approach by previous history of concussion education for parents

Figure 8 7.3 Constructs of the Health action Process Approach by previous history of concussion education for parents

7 6 No Education 5 Education 4 3 2 1

Median Score (IQR) Score Median 0

Figure 7.4 Constructs of the Health Action Process Approach by previous history of concussion education for coaches Figure 9 7.4 Constructs of the Health Action Process Approach by previous history of concussion education for coaches

7.00 6.00 No Education 5.00 Education 4.00 3.00 2.00 1.00 Median Score (IQR) Score Median 0.00

122 As suggested in the discussion sections of Chapter 4 and Chapter 5, further research is needed to address the limitations of concussion education intervention evaluation using a cross-sectional research design. Proposed projects should include the longitudinal assessment of the effectiveness of an education intervention aimed at targeting the key behaviours (e.g., player reporting, coach removal and parents assisting with referral) as well as the continual development of tools that can evaluate the effectiveness of the intervention on behaviour change. Future planned analyses include the examination of the association between parent and child knowledge beliefs and behaviours as well as the association between the coach and players’ knowledge beliefs and behaviour. The relationship between the constructs in the health behaviour change model will also be examined as they relate to behaviour change. Considering the barriers to concussion management identified in Chapter 3 and the limitations of education to address those barriers, future research should consider interventions that are more sophisticated in nature. For example, the socio-ecological model posits that interventions can occur at several levels: intrapersonal, interpersonal, institutional, community, or public policy level.313 Currently most of the research evaluates concussion education at the intrapersonal level. Future interventions can be designed to address more than one level at a time. Chapter 6 provides an example of how concussion prevention interventions can be highly effective at the policy level. The paper is part of a longstanding collaboration between the Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary and Hockey Canada. As a result of an evidence-informed decision to disallow body checking in all levels of Pee Wee ice hockey (ages 11-12), the risk of concussion in Pee Wee ice hockey players was reduced by 64%. Future directions for this research program include the evaluation of body checking policy changes in older age groups (i.e., Bantam ages 13-14, Midget ages 15-17) and body checking experience. Further, evaluation of the influence of body checking policy on player contact behaviours and performance in games is important to consider. In addition, the effect of coaching strategies aimed at teaching body awareness and appropriate checking techniques in players who are playing in body checking leagues should also be examined.

123 In conclusion, the evidence presented in this PhD dissertation suggests that generic education for parents, players and coaches may not be an effective secondary prevention strategy for concussion in youth ice hockey. Specifically, exposure to concussion education does not appear to be associated with sustained changes in concussion beliefs related to concussion management or the development of plans to do the behaviour. While more research is needed to evaluate the effectiveness of educational programs for parents and coaches that are informed by behavioural change theory, some evidence would suggest that there is potential for theory informed educational strategies to change concussion attitudes and potentially management behaviour. It is recommended that future concussion prevention interventions aim to address some of the barriers to appropriate concussion management for players, parents and coaches. Finally, rule changes reducing exposure to risk factors for concussion can be an effective primary concussion prevention strategy.

124 References

1. Hockey Canada. Annual report 2015-2016. www.hockeycanada.ca. Published 2016. Accessed December 1, 2016. 2. Hecimovich M. Sport Specialization in Youth: A Literature Review. J Am Chiropr Assoc. 2004;41(4):32-41. 3. Slutzky CB, Simpkins SD. The link between children’s sport participation and self-esteem: Exploring the mediating role of sport self-concept. Psychol Sport Exerc. 2009;10(3):381-389. doi:10.1016/j.psychsport.2008.09.006. 4. Zullig KJ, White RJ. Physical Activity, Life Satisfaction, and Self-Rated Health of Middle School Students. Appl Res Qual Life. 2010;6(3):277-289. doi:10.1007/s11482-010-9129-z. 5. Brenner JS, Brooks A, Demorest RA, et al. Reducing Injury Risk From Body Checking in Boys’ Youth Ice Hockey. Pediatrics. 2014;133(6):1151-1157. doi:10.1542/peds.2014-0692. 6. Black AM, Macpherson AK, Hagel BE, et al. Policy change eliminating body checking in non-elite ice hockey leads to a threefold reduction in injury and concussion risk in 11- and 12-year-old players. Br J Sports Med. 2016;50(1):55- 61. doi:10.1136/bjsports-2015-095103. 7. Matic GT, Sommerfeldt MF, Best TM, Collins CL, Comstock RD, Flanigan DC. Ice hockey injuries among United States high school athletes from 2008/2009– 2012/2013. Phys Sportsmed. 2015;43(2):119-125. doi:10.1080/00913847.2015.1035210. 8. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747-755. doi:10.1177/0363546511435626. 9. Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. CMAJ. 2011;183(11):1249-1256. doi:10.1503/cmaj.101540. 10. Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA. 2010;303(22):2265-2272.

125 doi:10.1001/jama.2010.755. 11. Emery CA, Meeuwisse WH. Injury rates, risk factors, and mechanisms of injury in minor hockey. Am J Sports Med. 2006;34(12):1960-1969. doi:10.1177/0363546506290061. 12. Pfister T, Pfister K, Hagel B, Ghali WA, Ronksley PE. The incidence of concussion in youth sports: a systematic review and meta-analysis. Br J Sports Med. 2015:bjsports-2015-094978. doi:10.1136/bjsports-2015-094978. 13. Moser RS, Schatz P, Jordan BD. Prolonged effects of concussion in high school athletes. Neurosurgery. 2005;57(2):306. doi:10.1227/01.NEU.0000166663.98616.E4. 14. Iverson GL, Gaetz M, Lovell MR, Collins MW. Cumulative effects of concussion in amateur athletes. Brain Inj. 2004;18(5):433-443. doi:10.1080/02699050310001617352. 15. Ponsford J, Willmott C, Rothwell A, et al. Cognitive and behavioral outcome following mild traumatic head injury in children. J Head Trauma Rehabil. 1999;14(4):360-372. 16. Belanger HG, Spiegel E, Vanderploeg RD. Neuropsychological performance following a history of multiple self-reported concussions: a meta-analysis. J Int Neuropsychol Soc. 2010;16(2):262-267. doi:10.1017/S1355617709991287. 17. Wetjen NM, Pichelmann MA, Atkinson JLD. Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg. 2010;211(4):553-557. doi:10.1016/j.jamcollsurg.2010.05.020. 18. Adler RH. Youth Sports and Concussions: Preventing Preventable Brain Injuries. One Client, One Cause, and A New Law. Phys Med Rehabil Clin N Am. 2011;22(4):721-728. doi:10.1016/j.pmr.2011.08.010. 19. K.G. H, J.A. D, M. G, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26. 20. Smith AM, Stuart MJ, Greenwald RM, et al. Proceedings from the Ice Hockey Summit on concussion: a call to action. PM R. 2011;3(7):605-612. doi:10.1016/j.pmrj.2011.05.013. 21. McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in

126 sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;23(2):89-117. doi:10.1097/JSM.0b013e31828b67cf. 22. Karlin AM. Concussion in the Pediatric and Adolescent Population: “Different Population, Different Concerns.” PM&R. 2011;3(10):S369-S379. doi:10.1016/j.pmrj.2011.07.015. 23. Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126(2):e374-81. doi:10.1542/peds.2009-0925. 24. Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. Jama. 2016;315(10):1014-1025. doi:10.1001/jama.2016.1203. 25. Toledo E, Lebel A, Becerra L, et al. The young brain and concussion: Imaging as a biomarker for diagnosis and prognosis. Neurosci Biobehav Rev. 2012;36(6):1510- 1531. 26. Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers ’ Association Related Concussion. 2004;39(3):280-297. 27. Benson BW, McIntosh AS, Maddocks D, Herring SA, Raftery M, Dvorák J. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med. 2013;47(5):321-326. doi:10.1136/bjsports-2013-092216. 28. Smith AM, Jorgenson M, Sorenson MC, et al. Hockey Education Program (HEP): A Statewide Measure of Fair Play, Skill Development, and Coaching Excellence. J ASTM Int. 2009;6(4):101857. doi:10.1520/JAI101857. 29. Navarro RR. Protective equipment and the prevention of concussion - what is the evidence? Curr Sports Med Rep. 2011;10(1):27-31. doi:10.1249/JSR.0b013e318205e072. 30. Cantu RC. Cerebral concussion in sport. Management and prevention. Sport Med. 1992;14(1):64-74. 31. Denke NJ. Brain Injury in Sports. J Emerg Nurs. 2008;34(4):363-364. doi:10.1016/j.jen.2008.04.013. 32. Echlin PS. Concussion education, identification, and treatment within a

127 prospective study of physician-observed junior ice hockey concussions: social context of this scientific intervention. Neurosurg Focus. 2010;29(5):E7. doi:10.3171/2010.10.FOCUS10222. 33. Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 2010;31:399-418. doi:10.1146/annurev.publhealth.012809.103604. 34. Murgraff V, McDermott MR, Walsh J. Self-Efficacy and Behavioral Enactment: The Application of Schwarzer’s Health Action Process Approach to the Prediction of Low-Risk, Single-Occasion Drinking. J Appl Soc Psychol. 2003;33(2):339-361. doi:10.1111/j.1559-1816.2003.tb01900.x. 35. Elbin RJ, Sufrinko A, Schatz P, et al. Removal From Play After Concussion and Recovery Time. Pediatrics. 2016;138(3):no pagination. 36. Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM. “Playing Through It”: Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. J Athl Train. 2016;51(4):329-335. doi:10.4085/1062-6050-51.5.02. 37. Black AM, Hagel BE, Palacios-Derflingher L, Schneider KJ, Emery CA. The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada’s national body checking policy change. Br J Sports Med. 2017:bjsports-2016-097392. doi:10.1136/bjsports-2016-097392. 38. Gielen AC. Application of Behavior-Change Theories and Methods to Injury Prevention. Epidemiol Rev. 2003;25(1):65-76. doi:10.1093/epirev/mxg004. 39. Nathanson JT, Connolly JG, Yuk F, et al. Concussion Incidence in Professional Football: Position-Specific Analysis With Use of a Novel Metric. Orthop J Sport Med. 2016;4(1):2325967115622621. doi:10.1177/2325967115622621. 40. Willigenburg NW, Borchers JR, Quincy R, Kaeding CC, Hewett TE. Comparison of Injuries in American Collegiate Football and Club Rugby: A Prospective Cohort Study. Am J Sports Med. 2016;44(3):753-760. doi:10.1177/0363546515622389. 41. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311-319.

128 42. Shankar P.R.a Fields SK. CCL. DRW. CRD. e f, Shankar PR, Fields SK, et al. Epidemiology of high school and collegiate football injuries in the United States, 2005-2006. Am J Sports Med. 2007;35(8):1295-1303. doi:10.1177/0363546507299745. 43. Badgeley MA, McIlvain NM, Yard EE, et al. Epidemiology of 10,000 high school football injuries: patterns of injury by position played. J Phys Act Health. 2013;10(2):160-169. 44. Kontos AP, Elbin RJ, Fazio-Sumrock VC, et al. Incidence of sports-related concussion among youth football players aged 8-12 Years. J Pediatr. 2013;163(3):717-720. doi:http://dx.doi.org/10.1016/j.jpeds.2013.04.011. 45. Dompier TP, Kerr ZY, Marshall SW, et al. Incidence of Concussion During Practice and Games in Youth, High School, and Collegiate American Football Players. JAMA Pediatr. 2015;169(7):659. doi:10.1001/jamapediatrics.2015.0210. 46. Zuckerman SL, Kerr ZY, Yengo-Kahn A, Wasserman E, Covassin T, Solomon GS. Epidemiology of Sports-Related Concussion in NCAA Athletes From 2009- 2010 to 2013-2014: Incidence, Recurrence, and Mechanisms. Am J Sports Med. 2015;43(11):2654-2662. doi:10.1177/0363546515599634. 47. Lincoln AE, Caswell S V, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958-963. doi:10.1177/0363546510392326. 48. Goodell R. Official Playing Rules of the National Football League.; 2015. 49. Kerr ZY, Collins CL, Mihalik JP, Marshall SW, Guskiewicz KM, Comstock RD. Impact Locations and Concussion Outcomes in High School Football Player-to- Player Collisions. Pediatrics. 2014;134(3):489-496. doi:10.1542/peds.2014-0770. 50. Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Forbes J a, Sills AK. Recovery from sports-related concussion: Days to return to neurocognitive baseline in adolescents versus young adults. Surg Neurol Int. 2012;3:130. doi:10.4103/2152- 7806.102945. 51. Casson IR, Viano DC, Powell JW, Pellman EJ. Twelve years of national football league concussion data. Sports Health. 2010;2(6):471-483. doi:10.1177/1941738110383963.

129 52. Meehan 3rd WP, d’Hemecourt P, Comstock RD, Meehan 3rd WP, d’Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: Mechanism, symptoms, and management. Am J Sports Med. 2010;38(12):2405- 2409. doi:10.1177/0363546510376737. 53. Delaney JS, Al-Kashmiri A, Correa JA. Mechanisms of injury for concussions in university football, ice hockey, and soccer. Clin J Sport Med. 2014;24(3):233-237. doi:10.1097/JSM.0000000000000017. 54. Alternative Dispute Resolution Center. NFL, Retired Players Resolve Concussion Litigation; Court Apointed Mediator Hails “Historic” Agreement. Newport Beach, CA, USA; 2013. 55. Swartz EE, Broglio SP, Cook SB, et al. Early results of a helmetless-tackling intervention to decrease head impacts in football players. J Athl Train. 2015;50(12):1219-1222. doi:10.4085/1062-6050-51.1.06. 56. Australian Football League. About the AFL. Docklands, VIC, Australia; 2016. 57. Orchard J, Seward H, Orchard J. 2012 AFL Injury Report. 2013:1-26. 58. Gibbs N, Bates D, Watsford M. Concussion Management in a Professional Senior AFl Team Over 10 Years: Assessing re-injury and performance. In: Annual Scientific Conference of the Australian College of Sports Physicians. Surfers Paradise, QLD, Australia; 2009:1-3. 59. Makdissi M, McCrory P, Ugoni A, Darby D, Brukner P. A prospective study of postconcussive outcomes after return to play in Australian football. Am J Sports Med. 2009;37(5):877-883. doi:10.1177/0363546508328118. 60. Austalian Football League Research Board Australian Football League Medical Officers’ Association. The Management of Concussion in Australian Football. Docklands, VIC, Australia; 2011. 61. Orchard J, Seward H, Orchard J. AFL Injury Report. AFL Reports. 2014:1-26. 62. Australian Football League. Laws of Australian Football. Docklands, VIC, Australia; 2016. 63. McIntosh AS, McCrory P, Comerford J. The dynamics of concussive head impacts in rugby and Australian rules football. Med Sci Sports Exerc. 2000;32(12):1980- 1984. doi:10.1097/00005768-200012000-00002.

130 64. National Collegiate Athletic Association. Student-Athlete Participation 1981-82- 2014-15 NCAA Sports Sponsorship and Participation Rates Report. https://www.ncaa.org/. Published 2015. Accessed May 6, 2016. 65. The National Federation of State High School Associations. 2014-15 High School Athletics Participation Survey.; 2015. 66. Gessel LMLM, Fields SKSK, Collins CLCL, et al. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495-503. 67. Dick R, L SE, Agel J, et al. Descriptive epidemiology of collegiate men’s baseball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 Through 2003-2004. J Athl Train. 2007;42(2):183-193. 68. Castile L, Collins CL, McIlvain NM, Comstock RD. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports Med. 2012;46(8):603-610. 69. Green GA, Pollack KM, D’Angelo J, et al. Mild Traumatic Brain Injury in Major and Minor League Baseball Players. Am J Sports Med. 2015;43(5):1118-1126. doi:10.1177/0363546514568089. 70. Cantu RC, Mueller FO. The prevention of catastrophic head and spine injuries in high school and college sports. Br J Sports Med. 2009;43(13):981-986. 71. Rosenbaum D, Davis S. Injury Risk Due to Collisions in Major League Baseball. Int J Sports Med. 2014;35(8):704-707. doi:10.1055/s-0033-1363253. 72. Fridman L, Fraser-Thomas JL, McFaull SR, Macpherson AK. Epidemiology of sports-related injuries in children and youth presenting to Canadian emergency departments from 2007-2010. BMC Sports Sci Med Rehabil. 2013;5:30. doi:10.1186/2052-1847-5-30. 73. Pappas E, Zazulak BT, Yard EE, Hewett TE. The Epidemiology of Pediatric Basketball Injuries Presenting to US Emergency Departments: 2000-2006. Sports Health. 2011;3(4):331-335. 74. Borowski LA, Yard EE, Fields SK, et al. The epidemiology of US high school basketball injuries, 2005-2007. Am J Sports Med. 2008;36(12):2328-2335. doi:10.1177/0363546508322893. 75. Rechel JA, Yard EE, Comstock RD. An Epidemiologic Comparison of High

131 School Sports Injuries Sustained in Practice and Competition. J Athl Train. 2008;43(2):197-204. 76. Dick R, Hertel J, Agel J, Grossman J, Marshall SW. Descriptive epidemiology of collegiate men’s basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42(2):194-201. 77. Rosenthal J a, Foraker RE, Collins CL, Comstock RD. National High School Athlete Concussion Rates From 2005-2006 to 2011-2012. Am J Sports Med. 2014;42(7):1710-1715. doi:10.1177/0363546514530091. 78. Padaki AS, Cole BJ, Ahmad CS. Concussion Incidence and Return-to-Play Time in National Basketball Association Players: Results From 2006 to 2014. Am J Sports Med. 2016;44(9):2263-2268. doi:10.1177/0363546516634679. 79. Finch C, Clapperton A, McCrory P. Increasing incidence of hospitalisation for sport-related concussion in Victoria, Australia. Med J Aust. 2013;198(May):427- 430. doi:10.5694/mja12.11217. 80. Bakhos LL, Lockhart GR, Myers R, Linakis JG. Emergency department visits for concussion in young child athletes. Pediatrics. 2010;126(3):e550-6. doi:10.1542/peds.2009-3101. 81. Labella CR, Smith BW, Sigurdsson A, C.R. L, B.W. S. Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc. 2002;34(1):41-44. doi:10.1097/00005768-200201000-00007. 82. Jacobson NA, Morawa LG, Bir CA. Epidemiology of cheerleading injuries presenting to NEISS hospitals from 2002 to 2007. J Trauma Acute Care Surg. 2012;72(2):521-526. doi:10.1097/TA.0b013e31823f5fe3. 83. Meehan WP, Taylor AM, Proctor M. The pediatric athlete: younger athletes with sport-related concussion. Clin Sports Med. 2011;30(1):133-44, x. doi:10.1016/j.csm.2010.08.004. 84. Shields BJ, Fernandez SA, Smith GA. Epidemiology of Cheerleading Stunt- Related Injuries in the United States. J Athl Train. 2009;44(6):586-594. doi:10.4085/1062-6050-44.6.586. 85. Shields BJ, Smith GA. Cheerleading-related injuries to children 5 to 18 years of

132 age: United States, 1990-2002. Pediatrics. 2006;117(1):122-129. doi:10.1542/peds.2005-1139. 86. Engebretsen L, Steffen K, Alonso JM, et al. Sports injuries and illnesses during the London Summer Olympic Games 2012. Br J Sports Med. 2013;44(11):772-780. doi:10.1136/bjsm.2010.076992. 87. Junge A, Engebretsen L, Mountjoy ML, et al. Sports injuries during the Summer Olympic Games 2008. Am J Sports Med. 2009;37(11):2165-2172. doi:10.1177/0363546509339357. 88. Mukherjee S. Head and face injuries during the men’s field hockey Junior World Cup 2009. Am J Sports Med. 2012;40(3):686-690. doi:10.1177/0363546511426697. 89. Kriz PK, David Zurakowski R, Almquist JL, et al. Eye Protection and Risk of Eye Injuries in High School Field Hockey. Pediatrics. 2015;136(3):521-527. doi:10.1542/peds.2015-0216. 90. Dick R, Hootman JM, Agel J, Vela L, Marshall SW, Messina R. Descriptive Epidemiology of Collegiate Women’s Field Hockey Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2002–2003. J Athl Train. 2007;42(2):211-220. 91. Wasserman EB, Kerr ZY, Zuckerman SL, et al. Epidemiology of Sports-Related Concussions in National Collegiate Athletic Association Athletes From 2009-2010 to 2013-2014: Symptom Prevalence, Symptom Resolution Time, and Return-to- Play Time. Am J Sports Med. 2015;44(1):226-233. doi:10.1177/0363546515610537. 92. Yard EE, Comstock RD. Injuries sustained by pediatric ice hockey, lacrosse, and field hockey athletes presenting to United States Emergency Departments, 1990- 2003. J Athl Train. 2006;41(4):441-449. 93. Kriz PK, Comstock RD, Zurakowski D, Almquist JL, Collins CL, D’Hemecourt PA. Effectiveness of protective eyewear in reducing eye injuries among high school field hockey players. Pediatrics. 2012;130(6):1069-1075. 94. Batten J, White AJ, Anderson E. Preventing penalty corner injuries and head trauma in field hockey: time to consider the power play? Br J Sports Med.

133 2016:bjsports-2016-096201. doi:10.1136/bjsports-2016-096201. 95. Meehan WP, D’Hemecourt P, Collins CL, Comstock RD. Assessment and management of sport-related concussions in United States high schools. Am J Sports Med. 2011;39(11):2304-2310. doi:10.1177/0363546511423503. 96. J.W. O, M.R. L, K.E. P, et al. Survey of Injuries in Seattle Area Levels 4 to 10 Female Club Gymnasts. Clin J Sport Med. 2011;21(6):486-492. doi:10.1097/JSM.0b013e31822e89a8. 97. International Ice Hockey Federation. Survey of Players. http://www.iihf.com/iihf- home/the-iihf/survey-of-players/. Published 2015. Accessed April 13, 2016. 98. Hockey Canada. 2014-15 Annual Report. www.hockeycanada.ca. Published 2015. Accessed May 6, 2016. 99. USA Hockey. Membership Statistics. 2015. http://www.usahockey.com/page/show/839306-membership-statistics. Accessed April 13, 2016. 100. Koh JO, Cassidy JD, Watkinson EJ. Incidence of concussion in contact sports: a systematic review of the evidence. Brain Inj. 2003;17(10):901-917. doi:10.1080/0269905031000088869. 101. Emery CA, Hagel B, Decloe M, Carly M. Risk factors for injury and severe injury in youth ice hockey: a systematic review of the literature. Inj Prev. 2010;16(2):113-118. doi:10.1136/ip.2009.022764. 102. Kontos AP, Elbin RJ, Sufrinko A, et al. Incidence of Concussion in Youth Ice Hockey Players. Pediatrics. 2016;137(2):1-6. doi:10.1542/peds.2015-1633. 103. Putukian M, Lincoln AE, Crisco JJ, M. P, A.E. L. Sports-specific issues in men’s and women’s lacrosse. Curr Sports Med Rep. 2014;13(5):334-340. doi:10.1249/JSR.0000000000000092. 104. Lincoln AE, Hinton RY, Almquist JL, Lager SL, Dick RW. Head, face, and eye injuries in scholastic and collegiate lacrosse: a 4-year prospective study. Am J Sports Med. 2007;35(2):207-215. doi:10.1177/0363546506293900. 105. Dick R, Romani WA, Agel J, Case JG, Marshall SW. Descriptive epidemiology of collegiate men’s lacrosse injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 Through 2003-2004. J Athl Train.

134 2007;42(2):255-261. 106. Smith JT. Fighting for regulation: Mixed Martial Arts Legislation in the United States. Drake Law Rev. 2010;1(617). 107. Sanchez Garcia R, Malcolm D. Decivilizing, civilizing or informalizing? The international development of Mixed Martial Arts. Int Rev Sociol Sport. 2010;45(1):39-58. doi:10.1177/1012690209352392. 108. Canadian Medical Association. Canadian Medical Association Submision on Bill S-209, An Act to Amend the Criminal Code.; 2013. 109. American Medical Association. H-470.965 Ultimate and Extreme Fighting. https://www.ama-assn.org/ssl3/ecomm/PolicyFinderForm.pl?site=www.ama- assn.org&uri=/resources/html/PolicyFinder/policyfiles/HnE/H-470.965.HTM. 110. British Medical Association. Ban ultimate fighting as well as boxing, says BMA. http://web.bma.org.uk/pressrel.nsf/wlu/SGOY-76QEY8?OpenDocument. Published 2007. 111. American Medical Association. Mixed martial arts must be banned – AMA. http://www.amawa.com.au/mixed-martial-arts-must-be-banned-ama-wa/. Published 2013. 112. Discover UFC. Ways to Win. http://www.ufc.ca/discover/sport/ways-to-win. 113. Discover UFC. Championship UF. Rules and Regulations. 114. Buse GJ. No holds barred sport fighting: a 10 year review of mixed martial arts competition. Br J Sports Med. 2006;40(2):169-172. doi:10.1136/bjsm.2005.021295. 115. Ngai KM, Levy F, Hsu EB. Injury trends in sanctioned mixed martial arts competition: a 5-year review from 2002 to 2007. Br J Sports Med. 2008;42(8):686- 689. doi:10.1136/bjsm.2007.044891. 116. Hutchison MG, Lawrence DW, Cusimano MD, Schweizer TA. Head Trauma in Mixed Martial Arts. Am J Sports Med. 2014;42(6):1352-1358. doi:10.1177/0363546514526151. 117. Lystad RP, Gregory K, Wilson J. The Epidemiology of Injuries in Mixed Martial Arts: A Systematic Review and Meta-analysis. Orthop J Sport Med. 2014;2(1):2325967113518492. doi:10.1177/2325967113518492.

135 118. Schwartz ML, Hudson a R, Fernie GR, Hayashi K, Coleclough a a. Biomechanical study of full-contact karate contrasted with boxing. J Neurosurg. 1986;64(2):248-252. doi:10.3171/jns.1986.64.2.0248. 119. Butterwick DJ, Lafave MR, Lau BHF, Freeman T. Rodeo Catastrophic Injuries and Registry: Initial Retrospective and Prospective Report. Clin J Sport Med. 2011;21(3):243-248. 120. Butterwick DJ, Meeuwisse WH. Bull riding injuries in professional rodeo: Data for prevention and care. Phys Sportsmed. 2003;31(6):37-41. 121. Butterwick DJ, Hagel B, Nelson DS, LeFave MR, Meeuwisse WH. Epidemiologic analysis of injury in five years of Canadian professional rodeo. Am J Sports Med. 2002;30(2):193-198. 122. Mobile Sport Medicine System. Mobile Sport Medicine System 25 Year Injury Study. studylib.net/doc/7713989/25-year-injury-study---mobile-sports-medicine- systems. Published 2005. 123. Butterwick DJ, Brandenburg MA, Andrews DM, et al. Agreement Statement From the 1st International Rodeo Research and Clinical Care Conference, Calgary, Alberta, Canada (July 7-9, 2004). Clin J Sport Med. 2005;15(3):192-195. 124. Norton R, Wilson M. Rugby League Injuries and Patterns. New Zeal J Sport Med. 1995;33:428-434. 125. Gissane C, Jennings D, Kerr K, White J. Injury rates in rugby league football: impact of change in playing season. Am J Sports Med. 2003;31(6):954-958. 126. Gabbett TJ, Domrow N. Risk factors for injury in subelite rugby league players. Am J Sports Med. 2005;33(3):428-434. doi:10.1177/0363546504268407. 127. King DA, Hume PA, Milburn PD, Guttenbeil D. Match and training injuries in rugby league: a review of published studies. Sports Med. 2010;40(2):163-178. doi:10.2165/11319740-000000000-00000. 128. Hinton-Bayre AD, Geffen G, Friis P. Presentation and mechanisms of concussion in professional rugby league football. J Sci Med Sport. 2004;7(3):400-404. doi:10.1016/S1440-2440(04)80035-5. 129. National Rugby League. RLIF Bans Shoulder Charge. www.nrl.com. Published 2012.

136 130. New Zealand Rugby League. NZRL Supports Ruling on Shoulder Charges. www.nzrl.co.nz. Published 2012. 131. Gabbett TJ, Godbolt RJB. Training injuries in professional rugby league. J Strength Cond Res. 2010;24(7):1948-1953. doi:10.1519/JSC.0b013e3181ddad65. 132. Gabbett TJ. Influence of playing position on the site, nature, and cause of rugby league injuries. J Strength Cond Res. 2005;19(4):749-755. doi:10.1519/R-16504.1. 133. O’Connor D. NRL Surveillance Report 2009 Season. 2009. 134. King D, Clark T. Injuries in amateur representative rugby league over three years. New Zeal J Sport Med. 2012;39(2):48-51. 135. Orr R, Cheng HL. Incidence and characteristics of injuries in elite Australian junior rugby league players. J Sci Med Sport. 2015;19(3):212-217. doi:10.1016/j.jsams.2015.03.007. 136. Gabbett TJ. Influence of the limited interchange rule on injury rates in sub-elite Rugby League players. J Sci Med Sport. 2005;8(1):111-115. 137. World Rugby. Rugby Sevens. Dublin, Ireland; 2016. 138. Fuller CW, Taylor A, Raftery M. Epidemiology of concussion in men’s elite Rugby-7s (Sevens World Series) and Rugby-15s (Rugby World Cup, Junior World Championship and Rugby Trophy, Pacific Nations Cup and English Premiership). Br J Sports Med. 2015;49(7):478-483. doi:10.1136/bjsports-2013-093381. 139. Lopez V, Ma R, Weinstein MG, et al. Concussive Injuries in Rugby-7s: An American Experience and Current Review. Med Sci Sports Exerc. 2016;(January 2016):1. doi:10.1249/MSS.0000000000000892. 140. Australian Rugby League. Laws of Rugby League Sevens (7’s).; 2015. 141. King DA, Gabbett TJ, Dreyer C, Gerrard DF. Incidence of injuries in the New Zealand national rugby league sevens tournament. J Sci Med Sport. 2006;9(1- 2):110-118. doi:10.1016/j.jsams.2005.09.001. 142. World Rugby. Player Number. Dublin, Ireland; 2016. 143. McIntosh A, Dutfield R. Rugby Pathways: Final Report. Kensington, NSW, Australia; 2010. 144. McIntosh A, McCrory P, Best J. Rugby Headgear Study: Final Report. UNSW, Australia; 2005.

137 145. McIntosh A, Savage T, Dutfield R. Rugby Union Injury Surveillance Study: Final Report for 2008 Season. UNSW, Australia; 2009. 146. Gardner AJ, Iverson GL, Williams WH, Baker S, Stanwell P. A Systematic Review and Meta-Analysis of Concussion in Rugby Union. Sport Med. 2014;44(12):1717-1731. doi:10.1007/s40279-014-0233-3. 147. Kemp SPT, Hudson Z, Brooks JHM, Fuller CW. The epidemiology of head injuries in English professional rugby union. Clin J Sport Med. 2008;18(3):227- 234. doi:10.1097/JSM.0b013e31816a1c9a. 148. Brooks JHM. Epidemiology of injuries in English professional rugby union: part 2 training Injuries. Br J Sports Med. 2005;39(10):767-775. doi:10.1136/bjsm.2005.018408. 149. Holtzhausen LJ, Schwellnus MP, Jakoet I, Pretorius AL. The incidence and nature of injuries in South African rugby players in the rugby Super 12 competition. S Afr Med J. 2006;96(12):1260-1265. 150. Fuller CW, Laborde F, Leather RJ, Molloy MG. International Rugby Board Rugby World Cup 2007 injury surveillance study. Br J Sports Med. 2008;42(6):452-459. doi:10.1136/bjsm.2008.047035. 151. Fuller CW, Sheerin K, Targett S. Rugby World Cup 2011: International Rugby Board Injury Surveillance Study. Br J Sports Med. 2013;47(18):1184-1191. doi:10.1136/bjsports-2012-091155. 152. Kerr HA, Curtis C, Micheli LJ, et al. Collegiate rugby union injury patterns in New England: a prospective cohort study. Br J Sports Med. 2008;42(7):595-603. doi:10.1136/bjsm.2007.035881. 153. Brooks JHM, Fuller CW, Kemp SPT, Reddin DB. Epidemiology of injuries in English professional rugby union: part 1 match injuries. Br J Sports Med. 2005;39(10):757-766. doi:10.1136/bjsm.2005.018135. 154. Whitehouse T, Orr R, Fitzgerald E, Harries S, McLellan CP. The Epidemiology of Injuries in Australian Professional Rugby Union 2014 Super Rugby Competition. Orthop J Sport Med. 2016;4(3):2325967116634075. doi:10.1177/2325967116634075. 155. Hendricks S, Lambert M. Tackling in Rugby: Coaching Strategies for Effective

138 Technique and Injury Prevention. Int J Sports Sci Coach. 2010;5(1):117-135. 156. Bird YN, Waller AE, Marshall SW, Alsop JC, Chalmers DJ, Gerrard DF. The New Zealand Rugby Injury and Performance Project: V. Epidemiology of a season of rugby injury. Br J Sports Med. 1998;32(4):319-325. doi:10.1136/bjsm.32.4.319. 157. Collins CL, Micheli LJ, Yard EE, et al. Injuries sustained by high school rugby players in the United States, 2005-2006. Arch Pediatr Adolesc Med. 2008;162(1):49-54. doi:http://dx.doi.org/10.1001/archpediatrics.2007.1. 158. World Rugby. Regulation 12. Schedule 1. Specifications Relating to Players’ Dress. Law 4 - Players’ Clothing. Dublin, Ireland; 2015. 159. Patton DA, McIntosh AS. Considerations for the performance requirements and technical specifications of soft-shell padded headgear. Proc Inst Mech Eng Part P J Sport Eng Technol. 2016;230(1):29-42. doi:10.1177/1754337115615482. 160. Federation Internationale de Football Association. Big Count.; 2016. 161. Andersen TE, Arnason A, Engebretsen L, Bahr R. Mechanisms of head injuries in elite football. Br J Sports Med. 2004;38(6):690-696. 162. Pickett W, Streight S, Simpson K, Brison RJ. Head injuries in youth soccer players presenting to the emergency department. Br J Sports Med. 2005;39(4):226-31-31. doi:10.1136/bjsm.2004.013169. 163. Fuller CW, Junge A, Dvorak J, CW F, Junge A, Dvorak J. A six year prospective study of the incidence and causes of head and neck injuries in international football. Br J Sports Med. 2005;39 Suppl 1(SUPPL. 1):i3-9. doi:10.1136/bjsm.2005.018937. 164. Powell JW, Barber-Foss KD. Traumatic brain injury in high school athletes. J Am Med Assoc. 1999;282(10):958-963. doi:http://dx.doi.org/10.1001/jama.282.10.958. 165. Kirkendall DT, Jordan SE, Garrett WE. Heading and head injuries in soccer. Sports Med. 2001;31(5):369-386. 166. Kirkendall DT, Garrett WE. Heading in Soccer: Integral Skill or Grounds for Cognitive Dysfunction? J Athl Train. 2001;36(3):328-333. 167. Boden BP, Kirkendall DT, Garrett WE. Concussion incidence in elite college soccer players. Am J Sports Med. 1998;26(2):238-241. 168. Withnall C, Shewchenko N, Gittens R, Dvorak J. Biomechanical investigation of

139 head impacts in football. Br J Sports Med. 2005;39(Supplement 1):i49-57. doi:10.1136/bjsm.2005.019182. 169. Barr C, Beusenberg M. Probability of Concussion from Single Heading Events in Football. Br J Sports Med. 2001;35:367-377. 170. McCrory PR. Brain injury and heading in soccer. BMJ. 2003;327(7411):351-352. doi:10.1136/bmj.327.7411.351. 171. Asken MJ, Schwartz RC. Heading the Ball in Soccer: What’s the Risk of Brain Injury? Phys Sportsmed. 1998;26(11):37-44. doi:10.3810/psm.1998.11.1190. 172. Baroff GS. Is heading a soccer ball injurious to brain function? J Head Trauma Rehabil. 1998;13(2):45-52. 173. Niedfeldt MW. Head injuries, heading, and the use of headgear in soccer. Curr Sports Med Rep. 1991;10(6):324-329. doi:10.1249/JSR.0b013e318237be53. 174. Levy ML, Kasasbeh AS, Baird LC, Amene C, Skeen J, Marshall L. Concussions in soccer: a current understanding. World Neurosurg. 2012;78(5):535-544. doi:10.1016/j.wneu.2011.10.032. 175. Punnoose AR. Study raises concerns about “heading” in soccer, but jury is still out on risks. JAMA. 2012;307(10):1012-1014. doi:10.1001/jama.2012.231. 176. Tysvaer A, Storli O. Association football injuries to the brain. A preliminary report. Br J Sports Med. 1981;15(3):163-166. doi:10.1136/bjsm.15.3.163. 177. Tysvaer a T, Løchen E a. Soccer injuries to the brain. A neuropsychologic study of former soccer players. Am J Sports Med. 1991;19(1):56-60. doi:10.1177/036354659101900109. 178. Tysvaer A. Head and Neck Injuries in Soccer: Impact of Minor Trauma. Sport Med. 1992;14(13):200-213. 179. Matser JT, Kessels AGH, Lezak MD, Troost J. A Dose-Response Relation of Headers and Concussions With Cognitive Impairment in Professional Soccer Players A Dose-Response Relation of Headers and Concussions With Cognitive Impairment in Professional Soccer Players. J Clin Exp Neuropsychol. 2001;23(6):770-774. doi:10.1076/jcen.23.6.770.1029. 180. Witol AD, Webbe FM. Soccer heading frequency predicts neuropsychological deficits. Arch Clin Neuropsychol. 2003;18(4):397-417. doi:10.1016/S0887-

140 6177(02)00151-8. 181. Lipton ML, Kim N, Zimmerman ME, et al. Soccer heading is associated with white matter microstructural and cognitive abnormalities. Radiology. 2013;268(3):850-857. doi:10.1148/radiol.13130545. 182. Janda DH, Bir CA, Cheney AL. An evaluation of the cumulative concussive effect of soccer heading in the youth population. Inj Control Saf Promot. 2002;9:25-31 ST-An evaluation of the cumulative concus. doi:LR 20071115; JID: 100941859; ppublish. 183. Rutherford A, Stephens R, Potter D, Fernie G. Neuropsychological impairment as a consequence of football (soccer) play and football heading: preliminary analyses and report on university footballers. J Clin Exp Neuropsychol. 2005;27(3):299- 319. doi:10.1080/13803390490515504. 184. Kaminski TW, Cousino ES, Glutting JJ. Examining the Relationship Between Purposeful Heading in Soccer and Computerized Neuropsychological Test Performance. Res Q Exerc Sport. 2008;79(2):235-244. doi:10.1080/02701367.2008.10599486. 185. Kontos AP, Dolese A, Elbin III RJ, Covassin T, Warren BL. Relationship of soccer heading to computerized neurocognitive performance and symptoms among female and male youth soccer players. Brain Inj. 2011;25(12):1234-1241. 186. Barnes BC, Cooper L, Kirkendall DT, McDermott TP, Jordan BD, Garrett WE. Concussion history in elite male and female soccer players. Am J Sports Med. 1998;26(3):433-438. 187. Putukian M, Echemendia RJ, Mackin S. The acute neuropsychological effects of heading in soccer: a pilot study. Clin J Sport Med. 2000;10(2):104-109. doi:10.1097/00042752-200004000-00004. 188. Guskiewicz KM, Marshall SW, Broglio SP, Cantu RC, Kirkendall DT. No evidence of impaired neurocognitive performance in collegiate soccer players. Am J Sports Med. 2002;30(2):157-162. doi:LR 20041129; JID: 7609541; CON: Am J Sports Med. 2002 Mar-Apr;30(2):157-62. PMID: 11912081; CON: Am J Sports Med. 1996 Mar-Apr;24(2):205-10. PMID: 8775122; ppublish. 189. Broglio SP, Guskiewicz KM, Sell TC, Lephart SM. No acute changes in postural

141 control after soccer heading. Br J Sports Med. 2004;38(5):561-567. doi:10.1136/bjsm.2003.004887. 190. Mangus BC, Wallmann HW, Ledford M. Analysis of postural stability in collegiate soccer players before and after an acute bout of heading multiple soccer balls. Sports Biomech. 2004;3(2):209-220. doi:10.1080/14763140408522841. 191. Schmitt DM, Hertel J, Evans TA, Olmsted LC, Putukian M. Effect of an acute bout of soccer heading on postural control and self-reported concussion symptoms. Int J Sports Med. 2004;25(5):326-331. doi:http://dx.doi.org/10.1055/s-2004- 819941. 192. Straume-Naesheim TM, Andersen TE, Dvorak J, Bahr R. Effects of heading exposure and previous concussions on neuropsychological performance among Norwegian elite footballers. Br J Sports Med. 2005;39 Suppl 1:i70-7. doi:10.1136/bjsm.2005.019646. 193. Zetterberg H, Hietala MA, Jonsson M, et al. Neurochemical aftermath of amateur boxing. Arch Neurol. 2006;63(9):1277-1280. doi:10.1001/archneur.63.9.1277. 194. Comstock RD, Currie DW, Pierpoint LA, Grubenhoff JA, Fields SK. An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatr. 2015;169(9):830-837. doi:10.1001/jamapediatrics.2015.1062. 195. Covassin T, Moran R, Elbin RJ. Sex Differences in Reported Concussion Injury Rates and Time Loss From Participation: An Update of the National Collegiate Athletic Association Injury Surveillance Program From 2004-2005 Through 2008- 2009. J Athl Train. 2016;51(3):189-194. doi:10.4085/1062-6050-51.3.05. 196. Covassin T, Elbin RJ. The female athlete: the role of gender in the assessment and management of sport-related concussion. Clin Sports Med. 2011;30(1):125-31, x. doi:10.1016/j.csm.2010.08.001. 197. Office of the Comissioner of Baseball. Official Baseball Rules.; 2015. 198. Daneshvar DH, Nowinski CJ, McKee AC, et al. The epidemiology of sport-related concussion. Clin Sports Med. 2011;30(1):1-17. doi:10.1016/j.csm.2010.08.006. 199. Reeser JC, Gregory A, Berg RL, Comstock RD. A Comparison of Women’s Collegiate and Girls’ High School Volleyball Injury Data Collected Prospectively

142 Over a 4-Year Period. Sport Heal A Multidiscip Approach. 2015;7(6):504-510. doi:10.1177/1941738115600143. 200. Yard EE, Collins CL, Dick RW, Comstock RD. An Epidemiologic Comparison of High School and College Wrestling Injuries. Am J Sports Med. 2007;36(1):57-64. doi:10.1177/0363546507307507. 201. Abrahams S, Fie SM, Patricios J, Posthumus M, September A V. Risk factors for sports concussion: an evidence-based systematic review. Br J Sports Med. 2014;48(2):91-97. doi:10.1136/bjsports-2013-092734. 202. Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concussions during the 1997 Canadian Football League season. Clin J Sport Med. 2000;10(1):9-14. 203. Delaney JS, Lacroix VJ, Gagne C, et al. Concussions among university football and soccer players: A pilot study. Clin J Sport Med. 2001;11(4):234-240. doi:10.1097/00042752-200110000-00005. 204. Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concussions among university football and soccer players. Clin J Sport Med. 2002;12(6):331-338. doi:10.1097/00042752-200211000-00003. 205. Collins CL, Fletcher EN, Fields SK, et al. Neck strength: a protective factor reducing risk for concussion in high school sports. J Prim Prev. 2014;35(5):309- 319. doi:10.1007/s10935-014-0355-2. 206. Schneider KJ, Meeuwisse WH, Kang J, Schneider GM, Emery C a. Preseason reports of neck pain, dizziness, and headache as risk factors for concussion in male youth ice hockey players. Clin J Sport Med. 2013;23(4):267-272. doi:10.1097/JSM.0b013e318281f09f. 207. Hagel BE, Marko J, Dryden D, Couperthwaite AB, Sommerfeldt J, Rowe BH. Effect of bodychecking on injury rates among minor ice hockey players. CMAJ. 2006;175(2):155-160. doi:10.1503/cmaj.051531. 208. Macpherson A, Rothman L, Howard A. Body-checking rules and childhood injuries in ice hockey. Pediatrics. 2006;117(2):e143-7. doi:10.1542/peds.2005- 1163. 209. Jako P. Safety measures in amateur boxing. Br J Sports Med. 2002;36(6):394-395. doi:10.1136/bjsm.36.6.394.

143 210. Jákó P. Boxing. In: Kordi, N; Maffuli, N.; Wroble, RR; Wallace WA, ed. Combat Sports Medicine. London, England: Springer; 2009. 211. Zazryn TR, McCrory PR, Cameron PA. Injury Rates and Risk Factors in Competitive Professional Boxing. Clin J Sport Med. 2009;19(1):20-25. doi:10.1097/JSM.0b013e31818f1582. 212. Cohenca N, Roges RA, Roges R. The incidence and severity of dental trauma in intercollegiate athletes. J Am Dent Assoc. 2007;138(8):1121-1126. 213. Quarrie KL, Gianotti SM, Chalmers DJ, Hopkins WG. An evaluation of mouthguard requirements and dental injuries in New Zealand rugby union. Br J Sports Med. 2005;39(9):650-651. doi:10.1136/bjsm.2004.016022. 214. Tanaka Y, Maeda Y, Yang T-C, Ando T, Tauchi Y, Miyanaga H. Prevention of Orofacial Injury via the Use of Mouthguards among Young Male Rugby Players. Int J Sports Med. 2014;36(3):254-261. doi:10.1055/s-0034-1390498. 215. Benson BW, Hamilton GM, Meeuwisse WH, et al. Is protective equipment useful in preventing concussion? A systematic review of the literature. Br J Sports Med. 2009;43 Suppl 1(SUPPL. 1):i56-67. doi:10.1136/bjsm.2009.058271. 216. Greenhill DA, Navo P, Zhao H, Torg J, Comstock RD, Boden BP. Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players. Sports Health. 2016;8(3):238-243. doi:10.1177/1941738116639027. 217. Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurgery. 2006;58(2):275- 86-86. doi:10.1227/01.NEU.0000200441.92742.46. 218. Rowson S, Duma SM, Greenwald RM, et al. Can helmet design reduce the risk of concussion in football? J Neurosurg. 2014;120(4):919-922. doi:10.3171/2014.1.JNS13916. 219. McGuine TA, Hetzel S, McCrea M, Brooks MA. Protective equipment and player characteristics associated with the incidence of sport-related concussion in high school football players: a multifactorial prospective study. Am J Sports Med. 2014;42(10):2470-2478. doi:10.1177/0363546514541926. 220. Benson BW, Rose MS, Meeuwisse WH, Benson B.W.a Rose MS. MWH., B.W. B,

144 M.S. R. The impact of face shield use on concussions in ice hockey: a multivariate analysis. Br J Sports Med. 2002;36(1):27-32. doi:10.1136/bjsm.36.1.27. 221. Stuart MJ, Smith AM, Malo-Ortiguera SA, Fischer TL, Larson DR. A comparison of facial protection and the incidence of head, neck, and facial injuries in Junior A hockey players. A function of individual playing time. Am J Sports Med. 2002;30(1):39-44. 222. Crisco JJ, Greenwald RM. Let’s get the head further out of the game: a proposal for reducing brain injuries in helmeted contact sports. Curr Sports Med Rep. 2013;10(1):7-9. doi:10.1249/JSR.0b013e318205e063. 223. McIntosh AS, McCrory P, Finch CF, Best JP, Chalmers DJ, Wolfe R. Does padded headgear prevent head injury in rugby union football? Med Sci Sports Exerc. 2009;41(2):306-313. doi:10.1249/MSS.0b013e3181864bee. 224. McIntosh AS, McCrory P. Effectiveness of headgear in a pilot study of under 15 rugby union football. Br J Sports Med. 2001;35(3):167-169. doi:10.1136/bjsm.35.3.167. 225. Hollis SJ, Stevenson MR, McIntosh AS, Shores EA, Collins MW, Taylor CB. Incidence, Risk, and Protective Factors of Mild Traumatic Brain Injury in a Cohort of Australian Nonprofessional Male Rugby Players. Am J Sports Med. 2009;37(12):2328-2333. doi:10.1177/0363546509341032. 226. Delaney JS, Al-Kashmiri A, Drummond R, Correa J a. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. Br J Sports Med. 2008;42(2):110-5; discussion 115. doi:10.1136/bjsm.2007.037689. 227. Menger R, Menger A, Nanda A. Rugby headgear and concussion prevention: misconceptions could increase aggressive play. Neurosurg Focus. 2016;40(4):E12. doi:10.3171/2016.1.FOCUS15615. 228. Tuna EB, Ozel E. Factors affecting sports-related orofacial injuries and the importance of mouthguards. Sports Med. 2014;44(6):777-783. doi:10.1007/s40279-014-0167-9. 229. Farrington T, Onambele-Pearson G, Taylor RL, Earl P, Winwood K. A review of facial protective equipment use in sport and the impact on injury incidence. Br J

145 Oral Maxillofac Surg. 2012;50(3):233-238. doi:10.1016/j.bjoms.2010.11.020. 230. Winters J, DeMont R. Role of mouthguards in reducing mild traumatic brain injury/concussion incidence in high school football athletes. Gen Dent. 2014;62(3):34-38. 231. Singh GD, Maher GJ, Padilla RR, et al. Customized mandibular orthotics in the prevention of concussion/mild traumatic brain injury in football players: A preliminary study. Dent Traumatol. 2009;25(5):515-521. doi:10.1111/j.1600- 9657.2009.00808.x. 232. Warsh JM, Constantin S a, Howard A, Macpherson A. A systematic review of the association between body checking and injury in youth ice hockey. Clin J Sport Med. 2009;19(2):134-144. doi:10.1097/JSM.0b013e3181987783. 233. Emery CA, Black AM, Palacios-Derflingher L, Schneider KJ, Hagel BE. The Risk of Injury Associated With Body Checking among Pee Wee Ice Hockey Players: An evaluation of Hockey Canada’s National Body Checking Policy Change (Abstract). Clin J Sport Med. 2016;26(3):e95-96. 234. Bjørneboe J, Bahr R, Dvorak J, Andersen TE. Lower incidence of arm-to-head contact incidents with stricter interpretation of the Laws of the Game in Norwegian male professional football. Br J Sports Med. 2013;47(8):508-514. 235. Krolikowski M, Black A, Kang J, et al. Did Implementation of the Zero-Tolerance for Head Contact Rule Change the Risk of Concussion and Injury In Youth Ice Hockey Players In Alberta? (Abstract). Clin J Sport Med. 2015;25(1):0-3. 236. USA Hockey HQ. Heads Up, Don’t Duck Safety Video. YouTube. https://www.youtube.com/watch?v=rwu4mwkEMaQ. Published 2012. Accessed June 20, 2014. 237. Cobb BR, Urban JE, Davenport EM, et al. Head impact exposure in youth football: Elementary school ages 9-12 years and the effect of practice structure. Ann Biomed Eng. 2013;41(12):2463-2473. doi:10.1007/s10439-013-0867-6. 238. Kerr ZY, Yeargin S, Valovich McLeod TC, et al. Comprehensive Coach Education and Practice Contact Restriction Guidelines Result in Lower Injury Rates in Youth American Football. Orthop J Sport Med. 2015;3(7):1-8. doi:10.1177/2325967115594578.

146 239. Clark JF, Graman P, Ellis JK, et al. An Exploratory Study of the Potential Effects of Vision Training on Concussion Incidence in Football. Optom Vis Perform. 2015;3(2):116-125. 240. Ashbaugh A, McGrew C. The role of nutritional supplements in sports concussion treatment. Curr Sports Med Rep. 2016;15(1):16-19. doi:10.1249/JSR.0000000000000219. 241. Oliver JM, Jones MT, Kirk KM, et al. Effect of Docosahexaenoic Acid on a Biomarker of Head Trauma in American Football. Med Sci Sports Exerc. January 2016:1. doi:10.1249/MSS.0000000000000875. 242. Mills JD, Bailes JE, Sedney CL, Hutchins H, Sears B. Omega-3 fatty acid supplementation and reduction of traumatic axonal injury in a rodent head injury model. J Neurosurg. 2011;114(1):77-84. doi:10.3171/2010.5.JNS08914. 243. Roberts WO, Brust JD, Leonard B, Hebert BJ. Fair-play rules and injury reduction in ice hockey. Arch Pediatr Adolesc Med. 1996;150(2):140-145. 244. Roberts WO, Brust JD, Leonard B. Youth ice hockey tournament injuries: Rates and patterns compared to season play. Med Sci Sports Exerc. 1999;31(1):46-51. doi:http://dx.doi.org/10.1097/00005768-199901000-00009. 245. Mackenzie B, Vivier P, Reinert S, Machan J, Kelley C, Jacobs E. Impact of a State Concussion Law on Pediatric Emergency Department Visits. Pediatr Emerg Care. 2015;31(1):25-30. doi:10.1097/PEC.0000000000000325. 246. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2014;48(2):135-140. doi:10.1136/bjsports-2013-092498. 247. Glang A, Koester MC, Beaver SV, Clay JE, McLaughlin KA. Online training in sports concussion for youth sports coaches. Int J Sports Sci Coach. 2010;5(1):1-12. doi:10.1260/1747-9541.5.1.1. 248. Findler P. Should Kids Play (American) Football? J Philos Sport. 2015;42(3):443- 462. doi:10.1080/00948705.2015.1079132. 249. Ahmed OH, Hall EE. “It was only a mild concussion”: Exploring the description of sports concussion in online news articles. Phys Ther Sport. 2017;23:7-13. doi:10.1016/j.ptsp.2016.07.003.

147 250. Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F. Sports-and recreation- related concussions in US youth. Pediatrics. 2016;138 (1) (n(e20154635). doi:http://dx.doi.org/10.1542/peds.2015-4635. 251. Kerr ZY, Zuckerman SL, Wasserman EB, et al. Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes. JAMA Pediatr. 2016;170(7):647-653. doi:10.1001/jamapediatrics.2016.0073. 252. Thomas DJ, Coxe K, Li H, et al. Length of Recovery From Sports-Related Concussions in Pediatric Patients Treated at Concussion Clinics. 2017;0(0):1-8. 253. Chrisman SP, Schiff MA, Chung SK, et al. Implementation of concussion legislation and extent of concussion education for athletes, parents, and coaches in washington state. Am J Sports Med. 2014;42(5):1190-1196. doi:10.1177/0363546513519073. 254. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa. 255. Bramley H, Kroft C, Polk D, Newberry T, Silvis M. Do youth hockey coaches allow players with a known concussion to participate in a game? Clin Pediatr. 2012;51(3):283-287. doi:10.1177/0009922811422434. 256. Bazarian JJ, McClung J, Shah MN, et al. Mild traumatic brain injury in the United States, 1998-2000. Brain Inj. 2005;19(2):85-91. doi:10.1080/02699050410001720158. 257. Morrissey D, Raukar NP, Andrade-Koziol J, et al. Statewide assessment of the Rhode Island School and Youth Programs Concussion Act. J Trauma Acute Care Surg. 2014;77(3 SUPPL. 1):S8-S11. doi:10.1097/TA.0000000000000331. 258. Michie S, Abraham C. Interventions to change health behaviours: evidence-based or evidence-inspired? Psychol Health. 2004;19(1):29-49. doi:10.1080/0887044031000141199. 259. Concannon LG. Effects of Legislation on Sports-Related Concussion. Phys Med Rehabil Clin N Am. 2016;27(2):513-527. doi:10.1016/j.pmr.2015.12.006. 260. Hachem LD, Kourtis G, Mylabathula S, et al. Experience with Canada’s First Policy on Concussion Education and Management in Schools. Can J Neurol Sci. 2016;43(4):554-560. doi:http://dx.doi.org/10.1017/cjn.2016.41.

148 261. Baugh CM, Kroshus E, Bourlas AP, Perry KI. Requiring Athletes to Acknowledge Receipt of Concussion-Related Information and Responsibility to Report Symptoms: A Study of the Prevalence, Variation, and Possible Improvements. J Law, Med Ethics. 2014;42(3):297-313. doi:10.1111/jlme.12147. 262. Mrazik M, Dennison CR, Brooks BL, Yeates KO, Babul S, Naidu D. A qualitative review of sports concussion education: prime time for evidence-based knowledge translation. Br J Sports Med. 2015;49(24):1548-1553. doi:10.1136/bjsports-2015- 094848. 263. Eagles ME, Bradbury-Squires DJ, Powell MF, Murphy JR, Campbell GD, Maroun FB. The Impact of a Concussion-U Educational Program on Knowledge of and Attitudes about Concussion. Can J Neurol Sci / J Can des Sci Neurol. 2016;43(5):659-664. doi:10.1017/cjn.2016.263. 264. Cook DJ, Cusimano MD, Tator CH, Chipman ML. Evaluation of the ThinkFirst Canada, Smart Hockey, brain and spinal cord injury prevention video. Inj Prev. 2003;9(4):361-366. doi:10.1136/ip.9.4.361. 265. Kerr ZY, Register-Mihalik JK, Marshall SW, Evenson KR, Mihalik JP, Guskiewicz KM. Disclosure and non-disclosure of concussion and concussion symptoms in athletes: Review and application of the socio-ecological framework. Brain Inj. 2014;28(8):1009-1021. doi:10.3109/02699052.2014.904049. 266. Chinn NR, Porter P. Concussion reporting behaviours of community college student-athletes and limits of transferring concussion knowledge during the stress of competition. BMJ open Sport Exerc Med. 2016;2(1):e000118. doi:10.1136/bmjsem-2016-000118. 267. Miyashita TL, Diakogeorgiou E, VanderVegt C. Gender Differences in Concussion Reporting Among High School Athletes. Sport Heal A Multidiscip Approach. 2016;8(4):359-363. 268. Anderson BL, Gittelman MA, Mann JK, Cyriac RL, Pomerantz WJ. High School Football Playersʼ Knowledge and Attitudes About Concussions. Clin J Sport Med. 2016;26(3):206-209. doi:10.1097/JSM.0000000000000214. 269. Kroshus E, Baugh CM, Hawrilenko M, Daneshvar DH. Pilot Randomized Evaluation of Publically Available Concussion Education Materials: Evidence of a

149 Possible Negative Effect. Health Educ Behav. 2014;42(2):153-162. doi:10.1177/1090198114543011. 270. Kemp JL, Newton JD, White PE, Finch CF. Implementation of concussion guidelines in community Australian Football and Rugby League—The experiences and challenges faced by coaches and sports trainers. J Sci Med Sport. 2016;19(4):305-310. doi:10.1016/j.jsams.2015.03.010. 271. Schwarzer R, Luszczynska A, Ziegelmann JP, Scholz U, Lippke S. Social- cognitive predictors of physical exercise adherence: three longitudinal studies in rehabilitation. Health Psychol. 2008;27(1 Suppl):S54-63. doi:10.1037/0278- 6133.27.1(Suppl.).S54. 272. Sutton S. How does the Health Action Process Approach (HAPA) Bridge the Intention–Behavior Gap? An Examination of the Model’s Causal Structure. Appl Psychol. 2008;57(1):66-74. doi:10.1111/j.1464-0597.2007.00326.x. 273. Schwarzer R. Some Burning Issues in Research on Health Behavior Change. Appl Psychol. 2008;57(1):84-93. doi:10.1111/j.1464-0597.2007.00324.x. 274. Schwarzer R. Self-Efficacy in the Adoption and Maintenance of Health Behaviors: Theoretical Approaches and a New Model. In: Schwarzer R, ed. Self-Efficacy: Thought Control of Action. United States: Taylor & Francis; 1992:217-244. 275. Schwarzer R. Modeling Health Behavior Change: How to Predict and Modify the Adoption and Maintenance of Health Behaviors. Appl Psychol. 2008;57(1):1-29. doi:10.1111/j.1464-0597.2007.00325.x. 276. Renner B, Schwarzer R. Risk and Health Behaviours: Documentation of the Scales of the Research Project: “Risk Appraisal Consequences in Korea” (RACK) Second Edition. Online. http://www.gesundheitsrisiko.de/docs/RACKEnglish.pdf. Published 2005. 277. Schwarzer R, Luszczynska A. How to Overcome Health-Compromising Behaviors. Eur Psychol. 2008;13(2):141-151. doi:10.1027/1016-9040.13.2.141. 278. Rosenbaum AM, Arnett PA. The development of a survey to examine knowledge about and attitudes toward concussion in high-school students. J Clin Exp Neuropsychol. 2010;32(1):44-55. doi:10.1080/13803390902806535. 279. White PE, Newton JD, Makdissi M, et al. Knowledge about sports-related

150 concussion: is the message getting through to coaches and trainers? Br J Sports Med. 2014;48(2):119-124. doi:10.1136/bjsports-2013-092785. 280. Krol AL, Mrazik M, Naidu D, Brooks BL, Iverson GL. Assessment of symptoms in a concussion management programme: method influences outcome. Brain Inj. 2011;25(13-14):1300-1305. doi:10.3109/02699052.2011.624571. 281. Guilmette TJ, Malia L a, McQuiggan MD. Concussion understanding and management among New England high school football coaches. Bell Carek, Collins, Gosselin, Gouvier, Guilmette, Guskiewicz, Guskiewicz, Iverson, Lovell, Macciocchi, McClincy, McCrory, McLeod, Mori, Powell, Tonino, Vangsness, Wilier C, ed. Brain Inj. 2007;21(10):1039-1047. doi:10.1080/02699050701633080. 282. Schneider K, Meeuwisse W, Nettel-Aguirre A, et al. Cervico-vestibular physiotherapy in the treatment of individuals with persistent symptoms following sport-related concussion: A randomized controlled trial. Brain Inj. 2014;28 (5- 6)(5-6):796. doi:10.3109/02699052.2014.892379. 283. Goodman D, Bradley NL, Paras B, Williamson IJ, Bizzochi J. Video gaming promotes concussion knowledge acquisition in youth hockey players. J Adolesc. 2006;29(3):351-360. doi:10.1016/j.adolescence.2005.07.004. 284. Cusimano MD, Chipman M, Donnelly P, Hutchison MG. Effectiveness of an educational video on concussion knowledge in minor league hockey players: a cluster randomised controlled trial. Br J Sports Med. 2014;48(2):141-146. doi:10.1136/bjsports-2012-091660. 285. Hecimovicha M, Kingb D, Maraisc I. Player and parent concussion knowledge and awareness in youth Australian Rules Football. Sport J. April 2016:1-19. 286. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. doi:10.1186/1748-5908-6-42. 287. Kroshus E, Garnett B, Hawrilenko M, Baugh CM, Calzo JP. Concussion under- reporting and pressure from coaches, teammates, fans, and parents. Soc Sci Med. 2015;134:66-75. 288. Baugh CM, Kroshus E, Daneshvar DH, Stern RA. Perceived Coach Support and

151 Concussion Symptom-Reporting: Differences between Freshmen and Non- Freshmen College Football Players. J Law, Med Ethics. 2014;42(3):314-322. doi:10.1111/jlme.12148. 289. Michie S, Atkind L, West R. The Behaviour Change Wheel A Guide to Designing Interventions. 1st ed. Silverback Publishing; 2014. 290. Caron JG, Bloom GA, Falcao WR, Sweet SN. An examination of concussion education programmes: a scoping review methodology. Inj Prev. 2015;21(5):301- 308. doi:http://dx.doi.org/10.1136/injuryprev-2014-041479. 291. Rivara FP, Schiff M a, Chrisman SP, Chung SK, Ellenbogen RG, Herring S a. The effect of coach education on reporting of concussions among high school athletes after passage of a concussion law. Am J Sports Med. 2014;42(5):1197-1203. doi:10.1177/0363546514521774. 292. Kroshus E, Baugh CM, Daneshvar DH. Content, Delivery, and Effectiveness of Concussion Education for US College Coaches. Clin J Sport Med. 2016;26(5):391- 397. doi:10.1097/JSM.0000000000000272. 293. Glang AE, Koester MC, Chesnutt JC, et al. The effectiveness of a web-based resource in improving postconcussion management in high schools. J Adolesc Health. 2015;56(1):91-97. doi:10.1016/j.jadohealth.2014.08.011. 294. Parker EM, Gilchrist J, Schuster D, Lee R, Sarmiento K. Reach and Knowledge Change Among Coaches and Other Participants of the Online Course: “Concussion in Sports: What You Need to Know”. J Head Trauma Rehabil. 2015;30(3):198-206. doi:10.1097/HTR.0000000000000097. 295. T.C. VM, C. S, Yalovich McLeod TC, et al. Sport-related concussion misunderstanding among youth coaches. Clin J Sport Med. 2007;17(2):140-141. doi:10.1097/JSM.0b013e31803212ae. 296. Mannings C, Kalynych C, Joseph MM, Smotherman C, Kraemer DF. Knowledge assessment of sports-related concussion among parents of children aged 5 years to 15 years enrolled in recreational tackle football. J Trauma Acute Care Surg. 2014;77(3 Suppl 1):S18-22. doi:10.1097/TA.0000000000000371. 297. Sullivan SJ, Schneiders AG, Cheang C-W, et al. “What”s happening?’ A content analysis of concussion-related traffic on Twitter. Br J Sports Med. 2011;46(4):258-

152 263. doi:10.1136/bjsm.2010.080341. 298. Juhn MS, Brolinso G, Duffey T, et al. Violence and injury in ice hockey. Clin J Sport Med. 2002;12(1):46-51. 299. Hockey Canada. Referee’s Case Book/Rule Combination 2014- 2015. http://www.hockeycanada.ca/en-ca/Hockey- Programs/Officiating/Essentials/Downloads.aspx. Published 2014. Accessed July 16, 2015. 300. Richmond SA, McKay CD, Emery CA. Knowledge translation in sport injury prevention research: an example in youth ice hockey in Canada. Br J Sports Med. 2014;48(12):941-942. doi:10.1136/bjsports-2012-091921. 301. McKay CD, Meeuwisse WH, Emery CA. Informing body checking policy in youth ice hockey in Canada: a discussion meeting with researchers and community stakeholders. Can J Public Health. 2014;105(6):e445-9. 302. International Ice Hockey Federation. Canada bans U13 body-checking. News Archive. http://www.iihf.com/home-of-hockey/news/news- singleview/?tx_ttnews[tt_news]=7969&cHash=a99cef3720a7c2094abd933aa7072 c93. Published 2013. Accessed October 2, 2014. 303. Meeuwisse WH, Love EJ. Development, implementation, and validation of the Canadian Intercollegiate Sport Injury Registry. Clin J Sport Med. 1998;8(3):164- 177. 304. Emery CA, McKay CD, Campbell TS, Peters AN. Examining attitudes toward body checking, levels of emotional empathy, and levels of aggression in body checking and non-body checking youth hockey leagues. Clin J Sport Med. 2009;19(3):207-215. doi:10.1097/JSM.0b013e31819d658e. 305. McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Clin Neurosci. 2009;16(6):755-763. doi:10.1136/bjsm.2009.058248. 306. Krolikowski MP, Black AM, Palacios-Derflingher L, Blake TA, Schneider KJ, Emery CA. The Effect of the “Zero Tolerance for Head Contact” Rule Change on the Risk of Concussions in Youth Ice Hockey Players. Am J Sports Med. 2016.

153 doi:10.1177/0363546516669701. 307. StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP, 2015. 308. Royston P, White I. Multiple imputation by chained equations (MICE): Implementation in Stata. J Stat Softw. 2009;45(4):1-2-. doi:10.1093/ije/dyh299. 309. Guerriero RM, Proctor MR, Mannix R, Meehan WP. Epidemiology, trends, assessment and management of sport-related concussion in United States high schools. Curr Opin Pediatr. 2012;24(6):696-701. doi:10.1097/MOP.0b013e3283595175. 310. Hockey Canada. 2012 Annual Report. http://www.hockeycanada.ca/en- ca/Corporate/About/Basics/Downloads. Published 2012. Accessed October 16, 2014. 311. Hockey Canada. 2013 Annual Report. www.hockeycanada.ca. Published 2013. Accessed October 16, 2014. 312. Adler RH, Herring SA. Changing the culture of concussion: education meets legislation. PM R. 2011;3(10 Suppl 2):S468-70. doi:10.1016/j.pmrj.2011.08.006. 313. Belton K, Fuselli P. Section 2: Canadian Evidence-Informed Practice Model. In: Pike I, Richmond S, Rothman L, Macpherson A, eds. Canadian Injury Prevention Resource: An Evidence-Informed Guide to Injury Prevention in Canada. Toronto, Ontario: Parachute; 2015:35-114. 314. Tietze DC, Borchers J, Roewer BD, Hewett TE. A prospective, longitudinal analysis of division I collegiate football injuries. Clin J Sport Med. 2015;23(2):148. 315. Black AM, Sergio LE, Macpherson AK. The Epidemiology of Concussions : Number and Nature of Concussions and Time to Recovery Among Female and Male Canadian Varsity Athletes 2008 to 2011. Clin J Sport Med. 2016;0(0):1-5. doi:10.1097/JSM.0000000000000308. 316. Deitch JR, Starkey C, Walters SL, Moseley JB. Injury risk in professional basketball players: A comparison of Women’s National Basketball Association and National Basketball Association athletes. Am J Sports Med. 2006;34(7):1077- 1083. doi:10.1177/0363546505285383.

154 317. Gardner EC. Head, Face, and Eye Injuries in Collegiate Women’s Field Hockey. Am J Sports Med. 2015;43(8):2027-2034. doi:10.1177/0363546515588175. 318. Singh S, Smith GA, Fields SK, McKenzie LB. Gymnastics-related injuries to children treated in emergency departments in the United States, 1990-2005. Pediatrics. 2008;121(4):e954-960. doi:10.1542/peds.2007-0767. 319. Benson BW, Meeuwisse WH, Rizos J, Kang J, Burke CJ. A prospective study of concussions among National Hockey League players during regular season games: the NHL-NHLPA Concussion Program. Can Med Assoc J. 2011;183(8):905-911. doi:10.1503/cmaj.092190. 320. Dick R, Lincoln AE, Agel J, Carter EA, Marshall SW, Hinton RY. Descriptive epidemiology of collegiate women’s lacrosse injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42(2):262-269. 321. King DA. Incidence of injuries in the 2005 New Zealand national junior rugby league competition. New Zeal Jounal Sport Med. 2006;34(1):21-27. doi:10.1016/j.jsams.2005.09.001. 322. King DA, Gabbett TJ. Injuries in a national women’s rugby league tournament: an initial investigation. NZ J Sport Med. 2007;34(2):2-5. 323. Gabbett TJ. Incidence of injury in junior rugby league players over four competitive seasons. J Sci Med Sport. 2008;11(3):323-328. doi:10.1016/j.jsams.2007.06.003. 324. King D, Gabbett TJ. Amateur rugby league match injuries in New Zealand. New Zeal J Sport Med. 2009;36(1):16-21. 325. King DA, Gissane C. Injuries in amateur rugby league matches in New Zealand: a comparison between a division 1 and a division 2 premier grade team. Clin J Sport Med. 2009;19(4):277-281. doi:10.1097/JSM.0b013e3181a7c6b0. 326. O’Connor D. NRL Injury Surveillance Report: 2009 Season. Camperdown, NSW, Australia; 2009. 327. King D, Clark T, Gissane C. Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: a pilot study. J Neurol Sci. 2012;320(1-2):16-21. doi:10.1016/j.jns.2012.05.049.

155 328. Savage J, Hooke C, Orchard J, Parkinson R. The Incidence of Concussion in a Professional Australian Rugby League Team, 1998–2012. J Sports Med. 2013;2013:1-7. doi:10.1155/2013/304576. 329. Fuller CW, Junge A, DeCelles J, et al. “Football for Health”--a football-based health-promotion programme for children in South Africa: a parallel cohort study. Br J Sports Med. 2010;44(8):546-554. doi:10.1136/bjsm.2010.072223. 330. Lopez V, Galano GJ, Black CM, et al. Profile of an American Amateur Rugby Union Sevens Series. Am J Sports Med. 2012;40(1):179-184. doi:10.1177/0363546511427124. 331. Mc Fie S, Brown J, Hendricks S, et al. Incidence and Factors Associated With Concussion Injuries at the 2011 to 2014 South African Rugby Union Youth Week Tournaments. Clin J Sport Med. December 2015:1. doi:10.1097/JSM.0000000000000276. 332. Moore IS, Ranson C, Mathema P. Injury Risk in International Rugby Union: Three-Year Injury Surveillance of the Welsh National Team. Orthop J Sport Med. 2015;3(7):2325967115596194. doi:10.1177/2325967115596194. 333. Willigenburg NW, Geissler KE, Benjamin D, et al. Injuries in American Collegiate Club Rugby: A Prospective Study. Ann Sport Med Res. 2014;(1):1005. 334. King D, Brughelli M, Hume P, Gissane C. Concussions in amateur rugby union identified with the use of a rapid visual screening tool. J Neurol Sci. 2013;326(1- 2):59-63. doi:10.1016/j.jns.2013.01.012. 335. Peck KY, Johnston DA, Owens BD, Cameron KL. The Incidence of Injury Among Male and Female Intercollegiate Rugby Players. Sport Heal A Multidiscip Approach. 2013;5(4):327-333. doi:10.1177/1941738113487165. 336. Roberts SP, Trewartha G, England M, Shaddick G, Stokes K a. Epidemiology of time-loss injuries in English community-level rugby union. BMJ Open. 2013;3(11):1-8. doi:10.1136/bmjopen-2013-003998. 337. Chalmers DJ, Samaranayaka A, Gulliver P, McNoe B. Risk factors for injury in rugby union football in New Zealand: a cohort study. Br J Sports Med. 2012;46(2):95-102. doi:10.1136/bjsports-2011-090272. 338. Haseler CM, Carmont MR, England M. The epidemiology of injuries in English

156 youth community rugby union. Br J Sports Med. 2010;44(15):1093-1099. doi:10.1136/bjsm.2010.074021. 339. Nicol A, Pollock A, Kirkwood G, Parekh N, Robson J. Rugby union injuries in Scottish schools. J Public Health (Oxf). 2011;33(2):256-261. doi:10.1093/pubmed/fdq047. 340. Taylor AE, Fuller CW, Molloy MG. Injury surveillance during the 2010 IRB Women’s Rugby World Cup. Br J Sport Med. 2011;45(15):1243-1245. doi:10.1136/bjsports-2011-090024. 341. Schneiders AG, Takemura M, Wassinger CA. A prospective epidemiological study of injuries to New Zealand premier club rugby union players. Phys Ther Sport. 2009;10(3):85-90. doi:10.1016/j.ptsp.2009.05.001. 342. Schick DM, Molloy MG, Wiley JP. Injuries during the 2006 Women’s Rugby World Cup. Br J Sports Med. 2008;42(6):447-451. doi:10.1136/bjsm.2008.046672. 343. Best JP, McIntosh AS, Savage TN. Rugby World Cup 2003 injury surveillance project. Br J Sports Med. 2005;39(11):812-817. doi:10.1136/bjsm.2004.016402. 344. Nordstrom A, Nordstrom P, Ekstrand J. Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players. Br J Sport Med. 2014;48(19):1447-1450. doi:10.1136/bjsports-2013-093406. 345. O’Kane JW, Spieker A, Levy MR, et al. Concussion Among Female Middle- School Soccer Players. JAMA Pediatr. 2014;168(3):258. doi:10.1001/jamapediatrics.2013.4518. 346. Nilsson M, Hagglund M, Ekstrand J, Walden M. Head and neck injuries in professional soccer. Clin J Sport Med. 2013;23(4):255-260. doi:10.1097/JSM.0b013e31827ee6f8. 347. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med. 2011;45(7):553- 558. doi:10.1136/bjsm.2009.060582. 348. Yard EE, Schroeder MJ, Fields SK, Collins CL, Comstock RD. The epidemiology of United States high school soccer injuries, 2005-2007. Am J Sports Med. 2008;36(10):1930-1937. doi:10.1177/0363546508318047. 349. Pappas E. Boxing, wrestling, and martial arts related injuries treated in emergency

157 departments in the United States, 2002-2005. J Sport Sci Med. 2007;6(December 2006):58-61.

158

Appendices

159 Appendix A: Concussion Rates Across Sport, Level of Play and Country

Study Year(s) Country Sex (M- Level Concussion incidence male, F- Incidence 1000 P-H 1000 A-E % all female, U- proportion injuries unspecified) American Football Nathanson et al. 2012/2013- United M Professional - - G: 6.61 - (2016) )39 2013/2014 States Willigenburg et 2012/2013- United M Collegiate - - G: 4.35 21.00% al. (2016) 40 2014/2015 States P:0.82 O: 1.04 Dompier et al. 2012/2013- United M Youth - - G: 2.38 9.60% (2015)45 2013/2014 States P:0.59 O:0.99 High school - - G: 2.01 4.00% P:0.66 O: 0.92 Collegiate - - G: 3.74 8.00% P:0.53 O:0.83 Tietze et al. 2012 United M Collegiate - - O: 1.41 - (2015) 314 States Zuckerman et al. 2009/2010- United M Collegiate - - G: 3.01 - (2015)46 2013/2014 States P: 0.42 O: 0.67 Badgeley et al. Not reported United M High school - - - 12.50% (2013)43 States Kontos et al. 2011 United M Youth - - G: 6.16 - (2013)44 States P: 0.24 O:1.76 Lincoln et al. 1997/1988- United M High School - - O: 0.60 - (2011) 47 2007/2008 States Bakhos et al 2001-2005 United M&F Youth (Ages 0.08% - - - (2010)80 States 7-11) Youth (Ages 0.27% - - - 12-17) Gessel et al. 2005/2006 United M High School - - G: 1.55 10.5%* (2007)66 States P: 0.21 O: 0.47 Collegiate - - G: 3.02 7.0%* P: 0.39 O: 0.61 Hootman et al. 1988/1989- United M Collegiate - - O: 0.37 6.00% (2007)41 2003/2004 States Shankar et al. 2005/2006 United M High school - - - 12.00% (2007)42 States Collegiate - - - 14.00% Australian Football AFL Research Not reported Australia M Professional - G:5.5 - - Board and AFL Medical Officers’ Association (2011) 60 Gibbs et al. (2009) 2000-2009 Australia M Professional - G:13 - - 58 Makdissi et al. 2000-2003 Australia M Professional - G:5.6 - - (2009) 59

160 Study Year(s) Country Sex (M- Level Concussion male, F- incidence female, U- unspecified) Incidence 1000 P-H 1000 A-E % all proportion injuries Baseball Covassin et al. 2004/2005- United M Collegiate - - G: 0.26 - 195 (2016) 2008/2009 States P: 0.05 O: 0.12 Green et al. 2011/2012 North M Professional - - O: 0.42 - (2015) 69 America Zuckerman et al. 2009/2010- United M Collegiate - - G: 0.12 - (2015) 46 2013/2014 States P: 0.07 O: 0.09 Castile et al. 2005-2010 United U High School - - G: 0.077 - 68 (2012) States P: 0.014 O: 0.037 Marar et al. 2008-2010 United M High School - - G: 0.11 - 8 (2012) States P: 0.01 5.5%* O: 0.05 - Lincoln et al. 1997/1988- United M High School - - O: 0.06 - (2011) 47 2007-2008 States Bakhos et al 2001-2005 United U Ages 7-11 0.01% - - - (2010) 80 States Ages 12-17 0.03% - - - Dick et al. (2007) 1988/1999- United M Collegiate - - G: 0.19 3.30% 67 2003-2004 States P: 0.03 1.60% Gessel et al. 2005/2006 United U High School - - G: 0.08 3%* (2007)66 States P: 0.03 O: 0.05 U Collegiate - - G: 0.23 2.5%* P: 0.03 O: 0.09 Hootman et al. 1988/1999- United M Collegiate - - O: 0.07 2.50% (2007)41 2003/2004 States *Data estimated based on figures within studies

161 Study Year(s) Country Sex (M- Level Concussion male, F- incidence female, U- Incidence 1000 P-H 1000 A-E % all unspecified) proportion injuries Basketball Black et al. (2016) 2008/2009- Canada M Collegiate 27.59% - - - 315 2010/2011 F Collegiate 15.79% - - - Covassin et al. 2004/2005- United M Collegiate - - G: 0.61 - (2016)195 2008/2009 States P: 0.27 O: 0.33 F Collegiate - - G: 0.97 - P: 0.33 O: 0.47 Zuckerman et al. 2009/2010- United M Collegiate - - G: 0.56 - 46 (2015) 2013/2014 States P: 0.34 O: 0.39 F Collegiate - - G: 1.09 - P: 0.44 O: 0.60 Rosenthal et al. 2005/2006 United M High School - - O: 0.07 - 201477 States Rosenthal et al. 2011/2012 United M High School - - O:0.24 - 201477 States Rosenthal et al. 2005/2006 United F High School - - O: 0.22 - 201477 States Rosenthal et al. 2011/2012 United F High School - - O: 0.37 - 201477 States Liraz et al. 2007/2008- Canada M 5-19 years - - - ED: 2.3% 72 (2013) 2009/2010 F 5-19 years - - - ED: 2.1% Marar et al. 2008/2009- United M High School - - G: 0.39 10%* (2012) 8 2009/2010 States P: 0.06 O: 0.16 F High School - - G: 0.55 13%* P: 0.06 O: 0.21 Lincoln et al. 1997/1998- United M High School - - O: 0.10 - (2011) 47 2007/2008 States F High School - - O: 0.16 - Pappas et al. 2000-2006 United M & F Ages 7-17 - - - ED: 1.8% (2011)73 States Bakhos et al 2001-2005 United M&W Ages 7-11 0.01% - - - (2010)80 States Ages 12-17 0.04% - - - Borowski et al. 2005/2006- United M High School - - - G: 6% 74 (2008) 2006/2007 States P: 3% W High School - - - G: 14% P: 5% Rechel et al. 2005/2006 United M High School - - - G: 3.7% (2008) 75 States P: 3.4% W High School - - - G: 19.0% P: 3.3% Dick et al. (2007) 1988-1989- United M Collegiate - - G: 0.32 G: 3.6% 76 2003-2004 States P: 0.12 P: 3.0% Gessel et al. 2005/2006 United M High school - - G: 0.11 *4% 66 (2007) States P: 0.06 O: 0.07 Collegiate - - G: 0.45 *4% P: 0.22 O: 0.27 F High school - - G: 0.60 *12% P: 0.06 O: 0.21 Collegiate - - G: 0.85 *7% P: 0.31 O: 0.43 Hootman et al. 1988/1999- United M Collegiate - - O: 0.16 O:3.2% (2007)41 2003/2004 States W Collegiate - - O: 0.22 O:4.7% Deitch et al. NBA:1996- United M Professional - - G: 0.2 G:1.0 (2006) 316 2002 States WNBA: 1997- O:0.8% 2002 W Professional - - G: 0.6 G: 2.4% O: 1.8%

162

Study Year(s) Country Sex (M- Level Concussion male, F- incidence female, U- unspecified) Incidence 1000 P-H 1000 A-E % all proportion injuries Cheerleading Marar et al. 2008/2009- United F High School - - G: 0.12 O: 20.3% (2012) 8 2009/2010 States P: 0.14 O: 0.14 Lincoln et al. 1997/1998- United F High School - - O: 0.06 - (2011) 47 2007/2008 States

Meehan III (2011) 2009-2010 United F High School - - O: 0.12 O: 20.7% 95 States Shields et al. 2006-2007 United U All Star - - - O: 1.4% (2009) 84 States Collegiate - - - O: 12.5% High School - - - O: 5.7% Shields et al. 1990-2002 United U Ages 5-18 - - - ED: 3.5% (2006)85 States Field Hockey Black et al. (2016) 2008/2009- Canada F Collegiate 17.86% - - - 315 2010/2011 Gardner et al. 2004/2005- United F Collegiate - - O: 0.40 - (2015) 317 2008/2009 States Kriz et al. (2015) 2009-2013 United F High School - - MPE: O: - 89 States 0.03 No MPE: O: 0.08 Zuckerman et al. 2009/2010- United F Collegiate - - G: 1.11 - 46 (2015) 2013/2014 States P: 0.18 O: 0.40 Marar et al. 2008/2009- United F High School - - G: 0.41 O: 12%* 8 (2012) 2009/2010 States P: 0.14 O: 0.22 Lincoln et al. 1997/1998- United F High School - - O: 0.10 - (2011) 47 2007/2008 States

Hootman et al. 1988/1999- United F Collegiate - - O:0.18 O: 3.9% (2007) 41 2003/2004 States Dick et al. (2007) 1988/1999- United F Collegiate - - G:0.52 G:9.4% 90 2003/2003 States P:0.09 P:3.4% MPE: Mandatory Protective Eyewear, *Estimated based on Graph Gymnastics Zuckerman et al. 2009/2010- United F Collegiate - - G: 0.483 - 46 (2015) 2013/2014 States P: 0.243 O: 0.265 Marar et al. 2008/2009- United F High School - - G: 0.24 3%* (2012) 8 2009/2010 States P: 0.03 O: 0.07 Meehan III et al. 2009-2010 United F High School - - O: 0.08 3.40% (2011) 95 States Singh et al. (2008) 1990-2005 United M+F Ages 6-17 - - ED:1.7% 318 States Hootman et al. 1988/1999- United F Collegiate - - O:0.16 2.30% (2007)41 2003/2004 States

163 Study Year(s) Country Sex (M-male, Level Concussion F-female, U- incidence unspecified) Incidence 1000 P-H 1000 A-E % all proportion injuries Ice Hockey Black et al. (2016) 2011-2012 Canada M+F Pee Wee 0.07 G: 2.73 - G: 66% 6 O: 1.72 O: 64% Pee Wee ϖ 0.021 G: 1.82 - G: 57% O: 0.64 O: 58% Covassin et al. 2004/2005- United M Collegiate - - G: 2.07 - (2016) 195 2008/2009 States P: 0.16 O: 0.59 F Collegiate - - G: 1.78 - P: 0.29 O: 0.66 Kontos et al. 2012/2013- United M+F Youth (12- 0.0-93 - G: 2.46 - 102 (2016) 2013/2014 States 18) P: 1.17 O: 1.58 Youth (12- - - O: 2.84 - 14) Youth (15- - - O:1.18 - 18) Matic et al (2015) 2008/2009- United M High School - - G: 1.67 G: 30% 7 2012/2013 States P: 0.15 P: 21% O: 0.64 O: 28% Zuckerman et al. 2009/2010- United M Collegiate - - G: 2.49 - (2015)46 2013/2014 States P: 0.25 O: 0.79 F Collegiate - - G: 2.01 - P: 0.30 O: 0.75 Marar et al. 2008-2010 United M High School - - G: 1.46 8 (2012) States P: 0.11 O:22.2% O: 0.54 Benson et al. 1997/1998- North M Professional - G: 1.8 - - (2011) 319 2003-2004 America Emery et al. 2008-2009 Canada M+F Bantam 0.051 G: 0.79 - G: 20% (2011) 9 O: 0.53 O: 19% Bantam 0.05 G: 0.91 - G: 20% O: 0.57 O: 20% Bakhos et al 2001-2005 United M+F Ages 7-11 0.10% - - - (2010) 80 States Ages 12-17 0.29% - - - Emery et al. 2007-2008 Canada M+F Pee Wee 0.07 G: 1.47 - G:35% (2010) 10 O: 0.91 O:32% Pee Wee ϖ 0.021 G: 0.39 - G:29% O: 0.28 O:25% Hootman et al. 1988/1999- United M Collegiate - - O: 0.41 7.90% (2007) 41 2003/2004 States 2001/2002- United F Collegiate - - O: 0.91 18.30% 2003/2004 States Emery & 2004-2005 Canada M+F Atom ϖ - O: 0.24 - O:21% Meeuwisse (2006) Pee Wee - O: 0.81 - O:25% 11 Bantam - O: 0.97 - O:23% Midget - O: 0.82 - O:13% *Atom (9/10 years), Pee Wee (11/12), Bantam (13/14), Midget (15/16) ϖ Delineates age groups that played without body checking τ With previous body checking experience υ Without previous body checking experience

164 Study Year(s) Country Sex (M-male, Level Concussion F-female, U- incidence unspecified) Incidence 1000 P-H 1000 A-E % all proportion injuries Lacrosse Covassin et al. 2004/2005- United M Collegiate - - G: 2.30 - 195 (2016) 2008/2009 States P: 0.24 O: 0.54 F Collegiate - - G: 1.50 - P: 0.26 O: 0.50 Zuckerman et al. 2009/2010- United M Collegiate - - G: 0.931 - (2015) 46 2013/2014 States P: 0.195 O: 0.318 F Collegiate - - G: 1.308 - P: 0.330 O: 0.521 Liraz et al. (2013) 2007/2008- Canada M 5-19 years - - - ED:4.1% 72 2009/2010 F 5-19 years - - - ED:2.7% Marar et al. 2008/2009- United M High School - - G: 1.04 17%* (2012) 8 2009/2010 States P: 0.11 O: 0.40 F High School - - G: 0.86 21%* P:0.13 O:0.35 Lincoln et al. 1997/1998- United M High School - - O: 0.30 - (2011) 47 2007/2008 States

F High School - - O:0.20 Dick et al. (2007) 1988/1989- United F Collegiate - - G:0.70 G:9.8% 320 2003/2004 States P:0.15 P:4.6% Hootman et al. 1988/1999- United M Collegiate - - O:0.26 O:5.6% (2007)41 2003/2004 States F Collegiate - - O:0.25 O:6.3%

Lincoln et al. 2000/2001- United M Collegiate O:0.37 (2007)104 2003/2004 States F Collegiate O:0.32 M High School O:0.28 F High School O:0.21 Mixed Martial Arts Hutchison et al. 2006-2012 Undeclar M Professional 0.213 - KO: 64 - 116 (2014) ed TKO:95 O: 159 Ngai et al. 2002-2007 Undeclar U Professional - - KO: 15.4 - (2008) 115 ed Buse (2006) 114 1993-2003 Undeclar M Professional - - KO: 48.3 - ed KO stands for knockout and TKO stands for technical knockout Rugby League Gabbett (2005) 126 2000-2003 Australia M Semi- - G: 3 - - professional King (2006) 321 2005 New M U16 - G: 4.3 - - Zealand U18 - G:18.5 - - King et al. (2007) 2005 New F Professional - G:6.1 - 2.00% 322 Zealand Gabbett (2008) 323 2003-2006 Australia M U19 - G:4.6 - - King et al. (2009) 2006 New M Amateur - G:27.2 - 3.90% 324,325 Zealand 2008 New M Amateur - G:12.9 - 4.80% Zealand O’Connor (2009) 2008 Australia M Professional - G:2.5 - - 326 2009 Australia M Professional - G:4.3 - 6.10% King et al. (2012) 2008-2010 New M Amateur - G:19.3 - - 134 Zealand King et al. (2012) 2011 New M Amateur - G:12.1 - - 327 Zealand Savage et al. 1998-2012 Australia M Professional - G:28.3 - - (2013) 328 Orr et al. (2016) 2012 Australia M U16, U18 - G:4.8 - 7.30% 135 Study Year(s) Country Sex (M-male, Level Concussion

165 F-female, U- incidence unspecified) Incidence 1000 P-H 1000 A-E % all proportion injuries Rugby Sevens Fuller et al. 2008/2009 Internatio M Elite - G:2 - - (2010)329 nal Fuller et al. (2015) 2008/2009- Internatio M Elite - G:8.3 - - 138 2012/2013 nal Lopez et al. 2010 United M+F Amateur - G:8.1 - 14.60% (2016) 330 States Lopez et al. 2010-2013 United M Non-elite, - G:7.6 - - (2016) 139 States elite F Non-elite, - G:8.1 - - elite M+F Non-elite - G:6.4 - - Elite - G:18.3 - -

166 Study Year(s) Country Sex (M-male, Level Concussion F-female, U- incidence unspecified) Incidence 1000 P-H 1000 A-E % all proportion injuries Rugby Union Willigenburg et 2012-2014 United M Collegiate - - 2.5 16% al. (2016) 40 States Fuller et al. (2015) 2007/2008- England M Professional - 4.6 - - 138 2010/2011 2007, 2011 Internatio M Professional - 5.2 - - nal 2008, 2010- Internatio M U20 - 3.7 - - 2013 nal 2012, 2013 Pacific M Professional - 5.4 - - Islands McFie et al. 2011-2014 South M U13 - 8.3 - 10.90% (2015) 331 Africa Moore et al. 2012-2014 Wales M Professional - 13.8 - - 332 (2015) U16 - 9.1 - 19.00% U18 - 5.5 - 10.70% Willigenburg et 2012-2014 United M Collegiate - - 2.57 20% al. (2014) 333 States Fuller et al. (2013) 2011 Internatio M Professional - 7.8 - - 151 nal King et al. (2013) 2012 New M Amateur - 2.3 - - 334 Zealand Peck et al. (2013) 2006/2007- United M Collegiate - - 0.33 8.70% 335 2010/2011 States F Collegiate - - 0.44 15.00% Roberts et al. 2009/2010- England M Amateur, - 1.2 - 7.00% (2013) 336 2011/2012 Semi- professional Chalmers et al. 2004 New M U13-U18, - - - 7.80% (2012) 337 Zealand amateur Haseler et al. 2008/2009 England M U9-17 - 1.8 - - (2010) 338 Nicol et al. (2010) 2008/2009 Scotland M U11-U18 - 10.8 - - 339 Taylor et al. 2010 Internatio F Professional - - 10.30% (2010)340 nal McIntosh et al. 2002-2010 Australia M U7-U8 - 0 - - (2005, 2008, U9-U10 - 3.8 - - 2010) 143–145 U11-U12 - 6 - - U13 - 11.8 - - U14 - 8.9 - - U15 - 12.7 - - 2005-2007 Australia M Amateur - 8.7 - - Hollis et al. 225 Semi- - 8.4 - - (2009) professional Schneiders et al. 2002 New M Semi- - 2.9 - 5.50% (2009) 341 Zealand professional Collins et al. 2005-2006 United M High school - - - O:16.1% 157 (2008) States F High school - - - O:14.3% Fuller et al. (2008) 2007 Internatio M Professional - G:2.6 - - 150 nal Kemp et al. 2002/2003- England M Professional - G:4.1 - 4.30% (2008) 147 2004/2005 P:0.02 Kerr et al. (2008) 2005/2006 United M Collegiate - G: 2.16 - 12.80% 152 States P:0.37 F Collegiate - G: 1.58 - 5.30% P:0.30 Schick et al. 2006 Internatio F Professional - O: 0.56 - O:6.2% (2008) 342 nal Holtzhausen et al. 1999 South M Professional - G:0.17 - O:1.6% (2006) 149 Africa Best et al. (2005) 2003 Internatio M Professional - - - G: 2.1% 343 nal Brooks et al. 2002/2003- England M Professional - G: 4.4 - - (2005) 153 2003/2004

167 Study Year(s) Country Sex (M-male, Level Concussion F-female, U- incidence unspecified) Incidence 1000 P-H 1000 A-E % all proportion injuries Soccer Covassin et al. 2004/2005- United M Collegiate - - G:1.32 - 195 (2016) 2008/2009 States P:0.17 O:0.42 F Collegiate - - G:1.89 - P: 0.24 O:0.65 Comstock et al. 2005/2006- United M High school - - O: 0.28 - (2015) 194 2013/2014 States F High school - - O: 0.45 - Zuckerman et al. 2009/2010- United M Collegiate - - G: 0.97 - 46 (2015) 2013/2014 States P:0.18 O:0.34 F Collegiate - - G:1.94 - P:0.21 O:0.63 Nordstrom et al. 2001/2002- Europe M Professional - - O:9% (2014) 344 2011/2012 O’Kane et al. 2008-2012 United F Middle - - G:5.3 - (2014) 345 States school P:0.2 O:1.20 Nilsson et al. 2001/2002- Europe M Professional O: 0.06 (2013)346 2009/2010 Ekstrand et al. 2001-2008 Europe M Professional - O: 0.06 O:0.10% (2011) 347 Yard et al. (2008) 2005-2007 United M High School - - O:9.3% 348 States F High School - - O:12.2% Gessel et al. 2005/2006 United M High school - - G:0.59 O: *9.5% (2007) )66 States P:0.04 O:0.22 Collegiate - - G:1.38 O: *5% P:0.24 O:0.49 F High school - - G:0.97 O: *15% P:0.09 O:0.36 Collegiate - - G:1.80 O: P:0.25 *7% O:0.63 Hootman et al. 1988/1989- United M Collegiate - - O:0.28 O:3.9% (2007) 41 2003/2004 States F Collegiate - - O:0.41 O:5.3% Fuller et al. (2005) 1998-2004 Internatio M Professional - G:1.06 - - 163 nal F Professional - G:2.56 - - Softball Covassin et al. 2004/2005- United F Collegiate - - G: 0.37 - 195 (2016) 2008/2009 States P: 0.14 O: 0.23 Zuckerman et al. 2009/2010- United F Collegiate - - G: 0.56 - 46 (2015) 2013/2014 States P: 0.17 O: 0.33 Castile et al. 2005-2010 United U High School - - G: 0.147 - (2012) 68 States P: 0.074 O: 0.099 Marar et al. 2008-2010 United F High School - - G: 0.29 (2012) 8 States P: 0.09 13%* O: 0.16 Lincoln et al. 1997/1988- United F High School - - O: 0.11 - (2011) 47 2007-2008 States

Gessel et al. 2005/2006 United U High School - - G: 0.04 5.5%* (2007)66 States P: 0.09 O: 0.07 U Collegiate - - G: 0.37 4%* P: 0.07 O: 0.19 Hootman et al. 1988/1999- United F Collegiate - - O: 0.14 4.30%

168 (2007) 41 2003/2004 States Volleyball Black et al. (2016) 2008/2009- Canada M Collegiate 15.38% - - - 315 2010/2011 F Collegiate 10.00% - - - Zuckerman et al. 2009/2010- United F Collegiate - - G: 0.557 - (2015) 46 2013/2014 States P: 0.269 O: 0.357 Rosenthal et al. 2005/2006 United F High School - - O: 0.05 - (2014) 77 States Rosenthal et al. 2011/2012 United F High School - - O: 0.17 - (2014) 77 States Reeser et al. 2005/2006 United F Collegiate - - G: 0.25 G: 6.4% (2015) 199 2008/2009 States P: 0.18 P:4.4% O: 0.2 O:4.8% F High School - - G: 0.11 G: 7.9% P: 0.04 P: 3% O: 0.06 O: 8% Liraz et al.(2013) 2007/2008- Canada M 5-19 years - - ED:1.4% 72 2009/2010 F 5-19 years - - ED:2.1% Castile et al. 2005-2010 United U High School - - G: 0.10 - (2012) 68 States P: 0.04 O: 0.06 Marar et al. 2008/2009- United F High School - - G: 0.10 6%* 8 (2012) 2009/2010 States P:0.05 O:0.06 Rechel et al. 2005/2006 United F High School - - - G: 1.5% (2008) 75 States P: 4.2% Gessel et al. 2005/2006 United U High School - - G: 0.05 O: 3%* (2007) 66 States P: 0.05 O: 0.05 U Collegiate - - G: 0.13 O: 3.5%* P: 0.21 O: 0.18 Hootman et al. 1988/1999- United F Collegiate - - O:0.09 2.10% (2007) 41 2003/2004 States Wrestling Zuckerman et al. 2009/2010- United M Collegiate - - G: 5.55 - 46 (2015) 2013/2014 States P: 0.57 O: 1.09 Rosenthal et al. 2005/2006 United M High School - - O: 0.17 - 201477 States Rosenthal et al. 2011/2012 United M High School - - O: 0.57 - 201477 States Castile et al. 2005-2010 United U High School - - G: 0.32 - (2012) 68 States P: 0.10 O: 0.15 Marar et al. 2008/2009- United M High School - - G: 0.48 O:10%* (2012) 8 2009/2010 States P: 0.13 O: 0.22 Lincoln et al. 1997/1998- United M High School - - O: 0.17 - (2011)47 2007/2008 States

Yard et al. (2008) 2005/2006 United M High School - - - O:5.4% 200 States M Collegiate - - - O:5.8% Rechel et al. 2008 2005/2006 United M High School - - - G: 6.3% 75 States P: 5.6% Gessel et al. 2005/2006 United U High School - - G: 0.32 O: 5.5%* (2007) 66 States P: 0.13 O: 0.18 U Collegiate - - G: 1.00 O: 4.5%* P: 0.35 O: 0.42 Pappas (2007) 349 2002-2005 United M+F All ages - - - ED: 3.0% States Hootman et al. 1988/1999- United M Collegiate - - O:0.25 O:3.3% (2007) 41 2003/2004 States * estimated based on graph

169 Appendix B: Qualitative Interview Guide

Interview Preamble: [Hello, thank you for agreeing to take part in this research study and be interviewed for this project. My name is Amanda Black and I am trying to learn about parent’s and coaches experiences with hockey concussions and injury prevention. I am talking to the parents and coaches of hockey players, like you, to find out your ideas about managing hockey concussions and injury prevention. It is our hope that through these interviews we can customize educational programs for the parents of youth ice hockey players. The first part of the interview will take approximately 30-45 min, I will then show you educational resource and complete the session with a few more questions that should take 15-20 minutes. If you need to leave after the first part of the session, it’s okay we can reschedule another day. If you are willing, I would like to tape record the interview. The recording and transcripts will be kept anonymous and I will conceal your identity in any written reports. I’d like to remind you that your participation in this research is completely voluntary and you may choose not to answer any question or to stop the interview at any time. I have a few specific questions that I would like to ask you, but feel free to add any comments whenever you wish. Can we start?]

Interview Guide Topic 1: Participants’ Experience, Understanding, Beliefs and Previous Behaviour related to concussion prevention and management in youth ice hockey.

1.Tell me about your experiences with hockey concussions? Probes: a) What signs of concussion in a hockey player might cause a coach/parent to be concerned? b) When have you seen concussions occurring? c) What are the things other coaches/parents might do to manage a concussion? d) What can coaches/parents do to prevent concussions?

170

2. a) Parent: I’m going to get you to think about a time when either one of your children or a child you know was complaining of a slight headache after taking a bad hit to the boards. Can you walk me through your thoughts from the time of the collision? Probes: a) What led to your decision on whether they should go to the physician or not? b) Tell me about your experiences with healthcare providers following a concussion?

2. b) Coach: I’m going to get you to think about a time where as a coach you had to handle a child complaining of a slight headache after taking a bad hit to the boards. Can you walk me through your thoughts from the time of the collision? Probe: a) Can you tell me about how this experience compares to managing a concussion if it was your own child (rather than a player on your team)?

3. Can you tell me a bit about what it is like to be a hockey parent/coach? Probes: a) Parent probe: What lead to your decision to enroll your child in ice hockey? b) Coach probe: Why did you decide to coach hockey?

4. What do you think the risk of concussion is in ice hockey?

5. What advice would you give to coaches/parents at the start of the hockey season regarding how to prepare for the risk of a concussion in youth ice hockey? Probes: a) What have you personally done? b) Based on your experience, what might you do differently?

Topic 2: Concussion Education: Previous Experience 6. Tell me about the training you’ve received in managing concussions?

171

7. Based on the training you have received, how confortable do you feel about managing (your child’s) concussions?

8. Can you describe a time where you’ve educated others about concussions? Topic 2: Concussion Education: Educational Need 9. What are your thoughts on having mandatory concussion training for all parents?

10. What are your thoughts on having mandatory concussion training for all coaches?

11. Who else might benefit from concussion education?

Topic 2: Concussion Education: Education strategy

Imagine you are a member of a board that is responsible for making decisions regarding the needs for concussion education or the training of parents/coaches: 12. What might you recommend to the board regarding this need?

13. What concerns or issues might you have with the education?

14. What would you propose to rectify those concerns?

15. What topics would you like to see in a concussion educational program?

16. How might it be provided to coaches?

17. How might the education for a coach be different than the education for a parent?

[Have the participant go through CATT]

172 [I would now like to ask you about your experience with the CATT. This portion of the interview will take 15-20 min. Please remember there are no wrong answers. I did not design the materials and you will not hurt my feelings. Please feel free to say what you’re thinking]

Topic 3: After Exposure to CATT 18. What was your overall impression of the CATT?

19. Can you comment on the helpfulness of the CATT website and explain why you felt that way?

20. How has viewing the material available in the CATT changed your beliefs about concussion prevention and management?

21. Can you describe any changes you might make to the way you prevent or manage concussions after viewing this material provided in the CATT?

22. Can you think of reasons why a parent/coach might not want to complete this tool if provided access?

Topic 4: The effect of being in a study 23. How has participating in the University of Calgary hockey study affected you? Probes a) Your understanding of concussions b) Your beliefs about concussions c) Your management of concussions Note: The order of topic 4 may shift depending on the conversation

173 Appendix C Sample Themes and Full List of Quotes

Parents Experience Emotional Experience "I was kind of frightened for him because that's one of my biggest fears."- Father 1 ": At the time of the collision, and anytime my kids get hit in any way, and they're down on the ice, your heart's in your throat because you don't know what's happening. I tell them to get up as fast as they can, if they can. "- Mother 1 Scared, I think, and worried and urgent that I'd want to get it looked at right away, unfortunate and just hopeful that if we looked at it that it's going to be okay." -Mother 2

"Scared. The reason for the incident, first of all, is he was ... It was a practice and he skated into the board, so he wasn't hit, but I think like any instance where your child is hurt, you are scared. When you see them down on the ice and they don't get up, your heart is racing and you're waiting for that movement to tell you okay, he's going to be all right."- Mother 3

"I've seen kids get hit. Some kids you think that when they've been hit, you think, "Oh, concussion," and some are fine, and some aren't. When they get hit, you hear the it, and your first thought is, "Oh," but usually with a concussion is they lay there. Your first thought isn't concussion, but it's like, "Did they break something? What happened to them?" Then when they sit on the bench and they talk to the trainer, it's scary. It's a horrible feeling, even when it's not your own child." - Mother 5

"Usually, you get an immediate jolt in your stomach and panic and is that my kid. It’s the first things I go through my mind when I see something like that. Then I start thinking is he moving, do I see any movement? Is he moving? Is he getting up, what’s going on? Who’s out there? Is he okay? I just start thinking about is he breathing, is he moving, is he? Is he okay? You hold your breath until you see them move and get up. Then you completely ignore the game, because then you’re watching the child. Kids have had concussions in hockey, but they’ve been hurt in different sports and literally, you stop watching everything, because you’re just are focused on what your child is doing on the bench. Are they standing, are they crying, are they pure white or they seem like they’re … Did they get the wind knocked out? How are they reacting to the coaches? That just consumes your thought and your focus."- Mother 6

"I guess at the time of the collision first you're in a state of, "Was that my kid?" Then you confirm it's your kid, and you're like in a frozen kind of a state, you want that kid to get up or want your kid to start to as soon as possible become normal. There's a coach that runs out and crouches over that kid so the feelings there are just in complete suspension. Ultimately the kid gets up or is carried off and there's a clap and then depending on what happens next or how- Usually those hits to the board, they actually sound really bad sometimes and sometimes they're not really bad, they just shake the kid up, so you hope for that I guess it is sort of a hopeful thing and a very fearful thing. " -Father 4

174 "It was interesting, because I was sitting and watching. He got hit open ice. His head never hit anything. It was just the contrecoup. Not just. Went down. Tried to stand you, and it was literally the cartoon spaghetti legs that I'll never forget. I went, "Not good." I was working the box at the time. ".."My stomach turns now. I'm a much more nervous watcher and very concerned. Someone look at him. Someone look at him." -Mother 7 "Well, I mean you get a little angry at first. You're thinking these kids are here to have fun, to play, and I mean as a parent, especially Bantam last year, you do understand there's going to be some rough playing, but you don't expect a blindsided hit. I wouldn't say blind, it was almost from the side, but this kid came from one end of the ice to the other type thing and just dropped the shoulder into him of course in the danger zone. I mean if he'd know the kid was in front of him or just peripheral to him, he would have known he was coming. The kids are taught, if you know a hits coming, it's to stay down, put your stick up against the glass to kind of absorb some of the hit type thing. I mean I was a little angry at first and then of course then you're kind of concerned and worried after that"- Father 5

Powerless (A lack of "I would have liked to crawl on the ice at the moment, but we just wanted to control) see if he was going to stay in the game or trying to figure out if he was going to come off." -Father 1

"They don't like parents on the bench. They don't like parents running around getting in the way. It's a bit hard." -Mother 4 Trust "At that point, I'm completely out of the loop. I trust all their coaches, and have, that if they are complaining of a headache or if they think that it's a really major ... it's a major situation to keep them out of the game, then I let them make that decision, and then I'll just wait and see what happens. It's at the discretion of the coach what I'm seeing now, just inside is that coaches are pulling kids off more and they're making them sit out more." - Mother 1

"I think that’s the most important thing that what your physician or the person that is caring for your child, unless you think they're way off-board, they're the ones that know. They're the experts and I think you should trust them. If you really don't trust them, get a second opinion. Go and see another physician or some sort of medical person." - Mother 4

"Well, because I knew what I did years ago. Also, it just came into my head, "This is your kid. Don't move." and I trusted [Name of nurse on sideline]. This was towards the end of the season. I knew that [Name of nurse on sideline] got this. I just remember saying to myself, "[Name of Nurse on sideline]'s got this.""-- Mother 7

175 Appendix D Summary Statistics and HAPA Construct Items

Responses n (%) n negative n neutral n positive n 1 2 3 4 5 6 7 NA Median (%) (%) (%) Risk Perception

How likely is it that you will get a concussion playing ice hockey. (1 Not at all Likely --- 7 Extremely Likely) 25 62 143 299 192 45 26 230 299 263 792 (3.2%) (7.8%) (18.1%) (37.8%) (24.2%) (5.7%) (3.3%) 4 (29.0%) (37.8%) (33.2%)

How likely is it that you will have long lasting problems if you have a concussion. (1 Not at all Likely --- 7 Extremely Likely) 26 121 205 234 112 64 26 352 234 202 788 (3.3%) (15.4%) (26.0%) (29.7%) (14.2%) (8.1%) (3.3%) 4 (44.7%) (29.7%) (25.6%)

How bad is it for your health… (1 Not at all bad --- 7 Extremely Bad)

..to have symptoms of concussion and not tell anyone? 17 9 15 49 128 216 364 41 49 708 798 (2.1%) (1.1%) (1.9%) (6.1%) (16.0%) (27.1%) (45.6%) 6 (5.1%) (6.1%) (88.7%)

..to have a headache after a hard fall, hit to your head or body, or body check and not tell anyone? 15 14 34 105 175 211 243 63 105 629 797 (1.9%) (1.8%) (4.3%) (13.2%) (22.0%) (26.5%) (30.5%) 6 (7.9%) (13.2%) (78.9%)

..to feel dizzy after a hard fall, hit to your head or body, or body check and not tell anyone? 13 11 35 107 171 206 244 59 107 621 787 (1.7%) (1.4%) (4.4%) (13.6%) (21.7%) (26.2%) (31.0%) 6 (7.5%) (13.6%) (78.9%)

..to have a headache after a hard fall, hit to your head or body, or body check and keep playing? 14 19 34 93 134 195 305 67 93 634 794 (1.8%) (2.4%) (4.3%) (11.7%) (16.9%) (24.6%) (38.4%) 6 (8.4%) (11.7%) (79.8%)

".. to get dizzy after a hard fall, collision, or body check and keep playing?" 10 17 33 74 135 220 305 60 74 660 794 (1.3%) (2.1%) (4.2%) (9.3%) (17.0%) (27.7%) (38.4%) 6 (7.6%) (9.3%) (83.1%) Mean Score 5.18 (SD) 777 (0.98)

176 Responses n (%) n negative n neutral n positive n 1 2 3 4 5 6 7 NA Median (%) (%) (%)

Outcome Expectancies If I told my coach or parent about symptoms I have that could be due to a concussion… (1 Strongly Disagree --7 Strongly Agree) ..people will think I was soft or won’t think I’m tough.(R) 382 178 93 74 38 11 22 653 74 71 798 (47.9%) (22.3%) (11.7%) (9.3%) (4.8%) (1.4%) (2.8%) 2 (81.8%) (9.3%) (8.9%) ..my team would lose the game.(R) 445 150 76 79 26 6 13 671 79 45 795 (56.0%) (18.9%) (9.6%) (9.9%) (3.3%) (0.8%) (1.6%) 1 (84.4%) (9.9%) (5.7%) ..my teammates will think I made the right decision. 39 16 31 109 140 190 272 86 109 602 797 (4.9%) (2.0%) (4.2%) (14.1%) (17.6%) (23.8%) (34.1%) 6 (10.8%) (13.7%) (75.5%) ..my coach will be disappointed with me.(R) 573 117 45 34 12 7 6 735 34 25 794 (72.2%) (14.7%) (5.7%) (4.3%) (1.5%) (0.9%) (0.8%) 1 (92.6%) (4.3%) (3.1%) ..my mom/female guardian will be disappointed with me.(R) 650 81 22 21 8 3 7 5 753 21 18 797 (81.6%) (10.2%) (2.8%) (2.6%) (1.0%) (0.4%) (0.9%) (0.6%) 1 (94.5%) (2.6%) (2.3%)

..my dad/male guardian will be disappointed with me.(R) 600 91 38 27 18 4 7 09 729 27 29 794 (75.6%) (11.5%) (4.8%) (3.4%) (2.3%) (0.5%) (0.9%) (1.1%) 1 (91.8%) (3.4%) (3.7%) ..my teammates will be disappointed with me.(R) 491 141 64 54 15 9 18 696 54 42 792 (62.0%) (17.8%) (8.1%) (6.8%) (1.9%) (1.1%) (2.3%) 1 (87.9%) (6.8%) (5.3%) ..I will get the care I need to lower my chances of missing more hockey from the potential concussion. 35 19 16 75 105 170 376 70 75 651 796 (4.4%) (2.4%) (8.1%) (9.4%) (13.2%) (21.4%) (47.2%) 6 (8.8%) (9.4%) (81.8%) ..it will help stop my injury from getting worse. 40 25 24 68 85 170 383 89 68 638 795 (5.0%) (3.1%) (3.0%) (8.6%) (10.7%) (21.4%) (48.2%) 6 (11.2%) (8.6%) (80.3%) ..I will lose my position on the team.(R) 565 114 45 39 19 1 8 724 39 28 791 (71.4%) (14.4%) (5.7%) (4.9%) (2.4%) (0.1%) (1.0%) 1 (91.5%) (4.9%) (3.5%) ..I will not be able to play my next game even if it’s not a concussion.(R) 232 120 84 204 75 44 34 436 204 153 793 (29.3%) (15.1%) (10.6%) (25.7%) (9.5%) (5.5%) (4.3%) 3 (55.0%) (25.7%) (19.3%) 6.01 Mean Score (SD) 766 (0.78)

177

Responses n (%) n negative n neutral n positive n 1 2 3 4 5 6 7 NA Median (%) (%) (%) Action Self- Efficacy

If I had symptoms that could be due to a concussion.. (1 Strongly Disagree --7 Strongly Agree)

.. I am confident I can tell my coach. 10 9 19 40 77 145 497 38 40 719 797 (1.3%) (1.1%) (2.4%) (5.0%) (9.7%) (18.2%) (62.4%) 7 (4.8%) (5.0%) (90.2%)

.. I am confident I can tell my mom/ female guardian. 11 3 10 18 36 122 592 4 24 18 750 796 (1.4%) (0.4%) (1.3%) (2.3%) (4.5%) (15.3%) (74.4%) (0.5%) 7 (3.0%) (2.3%) (94.2%)

.. I am confident I can tell my dad/ male guardian. 10 8 9 21 38 124 577 9 27 21 739 796 (1.3%) (1.0%) (1.1%) (2.6%) (4.8%) (15.6%) (72.5%) (1.1%) 7 (3.4%) (2.6%) (92.8%)

I am confident.

I know when to tell my coach that I had symptoms of concussion. 13 7 20 62 123 201 372 40 62 696 798 (1.6%) (0.9%) (2.5%) (7.8%) (15.4%) (25.2%) (46.6%) 6 (5.0%) (7.8%) (87.2%)

..I know when to tell one of my parents/guardian I had symptoms of concussion. 12 5 14 37 90 216 423 31 37 729 797 (1.5%) (0.6%) (1.8%) (4.6%) (11.3%) (27.1%) (53.1%) 7 (3.9%) (4.6%) (91.5%) Mean Score 6.28 (SD) 795 (1.00)

178 Responses n (%) n negative n neutral n positive n 1 2 3 4 5 6 7 NA Median (%) (%) (%) Intention

I intend to tell my coach or parent/guardian about symptoms I have after a hard fall, collision or body check. 11 6 25 55 86 184 429 42 55 699 796 (1.4%) (0.8%) (3.1%) (6.9%) (10.8%) (23.1%) (53.9%) 7 (5.3%) (6.9%) (87.8%)

I will make an effort to tell my coach or parent/guardian about symptoms I have after a hard fall, collision or body check. 16 12 24 74 128 186 358 52 74 672 798 (2.0%) (1.5%) (3.0%) (9.3%) (16.0%) (23.3%) (44.9%) 6 (6.5%) (9.3%) (84.2%) Mean Score 5.98 (SD) 796 (1.23) Maintenance Self-Efficacy

I know I could tell my coach if I had symptoms from a concussion and possibly be removed from the game.

..even if I knew my teammates were counting on me. 17 14 31 118 145 164 306 62 118 615 795 (2.1%) (1.8%) (3.9%) (14.8%) (18.2%) (20.6%) (38.5%) 6 (7.8%) (14.8%) (77.4%)

..even if he/she expects me to go back into the game. 20 16 44 113 121 182 297 80 113 600 793 (2.5%) (2.0%) (5.5%) (14.2%) (15.3%) (23.0%) (37.5%) 6 (10.1%) (14.2%) (75.7%) ..even if it was before or during an important playoff game. 30 35 60 105 118 163 284 125 105 565 795 (3.8%) (4.4%) (7.5%) (13.2%) (14.8%) (20.5%) (35.7%) 6 (15.7%) (13.2%) (71.1%) Mean Score 5.51 (SD) 791 (1.46)

179 Responses n (%) n negative neutral positive n 1 2 3 4 5 6 7 NA Median (%) (%) (%) Recovery Self-Efficacy In spite of good intentions, sometim es it's hard to talk to your coach or parents/guardians right away if you start feeling symptoms of concussion. In cases where I don't tell my coach right away, I am confident I could tell my coach… ..after playing one shift. 39 20 45 89 113 160 329 104 89 602 795 (4.9%) (2.5%) (5.7%) (11.2%) (14.2%) (20.1%) (41.4%) 6 (13.1%) (11.2%) (75.7%) ..after completing a full period. 58 21 52 99 107 148 309 131 99 564 794 (7.3%) (2.6%) (6.5%) (12.5%) (13.5%) (18.6%) (38.9%) 6 (16.5%) (12.5%) (71.0%) ..at the end of the game. 90 29 40 71 64 120 379 159 71 563 793 (11.3%) (3.7%) (5.0%) (9.0%) (8.1%) (15.1%) (47.8%) 6 (20.1%) (9.0%) (71.0%) In cases where I don't tell my parents/guardian(s) right away, I am confident I could tell my parents/guardians… ..the next day. 48 19 26 48 85 154 283 64 32 438 796 (6.0%) (2.4%) (3.3%) (6.0%) (10.7%) (19.3%) (53.0%) 7 (12.0%) (6.0%) (82.0%) ..right before the next regular season game. 102 38 59 79 80 100 337 199 79 517 795 (12.8%) (4.8%) (7.4%) (9.9%) (10.1%) (12.6%) (42.4%) 6 (25.0%) (9.9%) (65.0%) ..right before the next playoff game. 133 48 56 87 67 81 319 237 87 467 791 (16.8%) (6.1%) (7.1%) (11.0%) (8.5%) (10.2%) (40.3%) 6 (30.0%) (11.0%) (59.0%) Me an Score 5.32 (SD) 785 (1.57) Planning If I think I have a concussion, I know who I’m supposed to tell. 7 6 6 26 38 141 572 19 26 751 796 (0.9%) (0.8%) (0.8%) (3.3%) (4.8%) (17.7%) (71.9%) 7 (2.4%) (3.3%) (94.3%) If I think I have a concussion, I know the right time to tell someone. 11 5 10 52 60 130 525 26 52 715 793 (1.4%) (0.6%) (1.3%) (6.6%) (7.6%) (16.4%) (66.2%) 7 (3.3%) (6.6%) (90.2%) Mean Score 6.10 (SD) 779 (1.04)

180 Appendix E Concussion Knowledge Beliefs and Behaviour Questionnaire (CKBBQ): Player Version

Child SSID______*office use only Team Number______Concussion Knowledge, Beliefs and Behaviour Questionnaire: Player Demographic Information Name: I am a: Male Female Date Completed: (mm/dd/yyyy) Region: Calgary Edmonton Vancouver Part 1 1. At what levels of play have you played organized hockey? [Please select all the levels that apply to you and fill in the corresponding division(s)] Timbit Novice (Divisions:______) Pee Wee (Divisions:______) Midget (Divisions:______) Tyke Atom (Divisions:______) Bantam (Divisions:______) 2. Who takes you to most of your hockey games and practices? (Please choose one.) Mom Dad Step mom Step dad Grandma Grandpa Other______3. How many times do you think you've had a concussion? 0 1 2 3 4 5 6 >6 4. How many times have you been told by a doctor you had a concussion? 0 1 2 3 4 >4 5. In the last year, have you been given information about concussions? No Yes 6. (a) Where do you get your information about concussion and how helpful is it? If yes, how helpful is the information you received? Did you get information from the following Not at all Extremely places? Helpful A little Somewhat Very Helpful Hockey Association No Yes 1 2 3 4 5 Coach No Yes 1 2 3 4 5 Parent(s)/ Guardian(s) No Yes 1 2 3 4 5 Doctors No Yes 1 2 3 4 5 Teachers No Yes 1 2 3 4 5 Research Articles No Yes 1 2 3 4 5 TV No Yes 1 2 3 4 5 Newspapers No Yes 1 2 3 4 5 Social media (Facebook, Twitter) No Yes 1 2 3 4 5 Magazines No Yes 1 2 3 4 5 Internet No Yes 1 2 3 4 5 Concussion Study No Yes 1 2 3 4 5 Other: ______No Yes 1 2 3 4 5

6b. If you have received information from your teachers or community hockey coaches, please check how you received the information from them. If someone else provided this type of information please indicate what they provided and who they were.

Teacher Coach Other______Fact sheet Yes No Yes No Yes No Booklet Yes No Yes No Yes No Video/DVD Yes No Yes No Yes No Presentation (In Person) Yes No Yes No Yes No Poster Yes No Yes No Yes No

7. Who would you like to get information about concussions from? (Please check all that apply) Your coach Your teacher(s) Other ______Your parent(s)/guardian(s) The internet I do not want to get information from anyone Your doctor Health Care Professionals (Your trainer, athletic therapist or physio)

Player Questionnaire v.4 _09.24.2015 Page 1 of 4

181 Part 2 Please answer the following True or False questions to the best of your ability. Please mark T for True, F for False and ? If you don't know. 1. People who have had one concussion are more likely to have another concussion. T F ? 2. Sometimes a second concussion can help a person remember things that were forgotten after the first concussion. T F ? 3. An athlete can return to play while experiencing symptoms of a concussion if directed to do so by an athletic trainer or a physician (doctor). T F ? 4. There are helmets that prevent all concussions. T F ? 5. A concussion is a brain injury. T F ? 6. Have you heard of the term “graduated return to play protocol” or "stepwise return to play" for concussion? YES NO ? 6. a) If yes, can you try to list the 6 stages? Stage 1 ______Stage 2 ______Stage 3 ______Stage 4 ______Stage 5 ______Stage 6 ______In the following scenarios what should someone do? Do Nothing (DN), Non-Urgent: Book an appointment with a doctor for a later day (NU), Urgent: Call 911/Player needs to go to Emergency now (ED). 7. After a collision, body check or fall a player starts throwing up over and over again. DN NU ED 8. After a collision, body check or fall a player has a headache that continues to get worse. DN NU ED 9. Immediately after a collision, body check, or fall a player complains of a headache and dizziness but starts to feel better by the end of the game. DN NU ED Please answer the following True or False questions to the best of your ability. Please mark T for True, F for False and ? If you don't know. 10. To have a concussion, you have to be knocked out. T F ? 11. There is a higher risk of long term problems if someone has a second concussion before recovering from the first one. T F ? 12. Concussions can sometimes lead to emotional problems. T F ? 13. Ice hockey is a game typically played with a puck. T F ? 14. A concussion can only happen if there is a direct hit to the head. T F ? 15. There will be few risks to my health when I am older if I have many concussions. T F ?

16. Younger players (under the age of 18) typically take longer to recover from a concussion than adults. T F ? 17. Post concussion symptoms may not appear until hours or days later. T F ? Think about someone who has had a concussion. Select Y for the following signs and symptoms that you believe someone may be likely to experience BECAUSE of a concussion, N for symptoms not associated with concussion and ? If you don't know. 18. Hives Y N ? 24. Panic Attacks Y N ? 30. Excessive Studying Y N ? 31. Difficulty 19. Headache Y N ? 25. Feeling Tired Y N ? Concentrating Y N ? 20. Fever Y N ? 26. Feeling in a Fog Y N ? 32. Dizziness Y N ? 21. Arthritis Y N ? 27. Weight Gain Y N ? 33. Hair Loss Y N ? 22. Sensitivity to Light Y N ? 28. Feeling Slowed Down Y N ? 23. Difficulty 29. Reduced Breathing Remembering Y N ? Rate Y N ?

Player Questionnaire v.4 _09.24.2015 Page 2 of 4

182 Part 3 Please rate the following from 1 Not at all Likely to 7 Extremely Likely. 1 Not at all Likely-- 4 Somewhat Likely-- 7 Extremely Likely 1. How likely is it that you will get a concussion playing ice hockey. 1 2 3 4 5 6 7 2. How likely is it that you will have long lasting problems if you have a concussion. 1 2 3 4 5 6 7

Please rate the following from 1 Not at all bad to 7 Extremely Bad. 1 Not at all bad-- 4 Moderately Bad-- 7 Extremely Bad 3-7. How bad is it for your health… 3. ..to have symptoms of concussion and not tell anyone? 1 2 3 4 5 6 7 4. ..to have a headache after a hard fall, hit to your head or body, or body check and not tell anyone? 1 2 3 4 5 6 7 5. ..to feel dizzy after a hard fall, hit to your head or body, or body check and not tell anyone? 1 2 3 4 5 6 7 6. ..to have a headache after a hard fall, hit to your head or body, or body check and keep playing? 1 2 3 4 5 6 7 7. ..to feel dizzy after a hard fall, hit to your head or body, or body check and keep playing? 1 2 3 4 5 6 7 Please choose how much you disagree or agree with the following statements: 1 Strongly Disagree to 7 Strongly Agree. Please select N/A if the person is not involved in these situations. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 8-18. If I told my coach or a parent about symptoms I have that could be due to a concussion… 8. ..people will think I was soft or won't think I'm tough. 1 2 3 4 5 6 7 9. ..my team will lose the game. 1 2 3 4 5 6 7 10. ..my teammates will think I made the right decision. 1 2 3 4 5 6 7 11. ..my coach will be disappointed with me. 1 2 3 4 5 6 7 12. ..my mom/female guardian will be disappointed with me. 1 2 3 4 5 6 7 N/A 13. ..my dad/male guardian will be disappointed with me. 1 2 3 4 5 6 7 N/A 14. ..my teammates will be disappointed with me. 1 2 3 4 5 6 7 15. ..I will get the care I need to lower my chances of missing more hockey from the potential concussion. 1 2 3 4 5 6 7 16. ..it will help stop my injury from getting worse. 1 2 3 4 5 6 7 17. ..I will lose my position on the team. 1 2 3 4 5 6 7 18. ..I will not be able to play my next game even if it's not a concussion. 1 2 3 4 5 6 7 19-21. If I had symptoms that could be due to a concussion… 19. I am confident I can tell my coach. 1 2 3 4 5 6 7 20. I am confident I can tell my mom/ female guardian. 1 2 3 4 5 6 7 N/A 21. I am confident I can tell my dad/ male guardian. 1 2 3 4 5 6 7 N/A 22-23. I am confident… 22. ..I know when to tell my coach that I had symptoms of concussion. 1 2 3 4 5 6 7 23. ..I know when to tell one of my parents/guardian I had symptoms of concussion. 1 2 3 4 5 6 7 24. I intend to tell my coach or parent/guardian about symptoms I have after a hard fall, collision, or body check. 1 2 3 4 5 6 7 25. If I had symptoms following a hit to my head that weren't that bad, I wouldn't tell my coach. 1 2 3 4 5 6 7 26. I will make an effort to tell my coach or parent/guardian about symptoms I have after a hard fall, collision or body check. 1 2 3 4 5 6 7

Player Questionnaire v.4 _09.24.2015 Page 3 of 4

183 Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 27-29. I know I could tell my coach if I had symptoms from a concussion and possibly be removed from the game… 27. ..even if I knew my teammates were counting on me. 1 2 3 4 5 6 7 28. ..even if he/she expects me to go back into the game. 1 2 3 4 5 6 7 29. ..even if it was before or during an important playoff game. 1 2 3 4 5 6 7 30. Is there anybody else you trust that you would tell about symptoms INSTEAD of your coaches or parents/guardians if you had symptoms of concussion? No Yes (Please List) ______In spite of good intentions, sometimes it’s hard to talk to your coach or parents/guardians right away if you start feeling symptoms of concussion. 31-33. In cases where I don’t tell my coach right away, I am confident I could tell my coach… 31. ..after playing one shift. 1 2 3 4 5 6 7 32. ..after completing a full period. 1 2 3 4 5 6 7 33. ..at the end of the game. 1 2 3 4 5 6 7 34-36. In cases where I don’t tell my parents/guardian(s) right away, I am confident I could tell my parents/guardians… 34. ..the next day. 1 2 3 4 5 6 7 35. ..right before the next regular season game. 1 2 3 4 5 6 7 36. ..right before the next playoff game. 1 2 3 4 5 6 7 37. If I think I have a concussion, I know who I'm supposed to tell. 1 2 3 4 5 6 7 38. If I think I have a concussion, I know the right time to tell someone. 1 2 3 4 5 6 7 39. My team or my parent(s)/guadian(s) have discussed with me what I'm supposed to do if I think I have a concussion. 1 2 3 4 5 6 7 Please give the best response for the following questions. Please be honest. Remember, your answers are confidential. 40.Over the last hockey season (2014-2015), did you experienced dizziness, headaches, neck pain or felt like you may have a concussion after a hard fall, collision, or body check? No Yes 41. How many times has the following happened AFTER a hard fall, collision or body check last hockey season (2014-2015 hockey season) You experienced dizziness, and continued to play in a game You experienced dizziness, and continued to play in a practice You experienced a headache, and continued to play in a game You experienced a headache, and continued to play in a practice You experienced neck pain, and continued to play in a game You experienced neck pain, and continued to play in a practice Felt like you may have a concussion, and didn't tell your coach Felt like you have a concussion, and didn't tell your parents Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 42. Playing hockey is fun. 1 2 3 4 5 6 7 43.I feel confortable reporting symptoms of a possible concussion to my coaches. 1 2 3 4 5 6 7 44.My coaches would be supportive and encouraging if I told them about symptoms I had that could be because of a concussion 1 2 3 4 5 6 7 45. I would encourage my teammate to tell someone and not play if they had possible concussion symptoms. 1 2 3 4 5 6 7 46. Concussions are a serious injury. 1 2 3 4 5 6 7 47. The 2013 rule change by Hockey Canada delaying body checking until Bantam decreased concussions in Pee Wee. 1 2 3 4 5 6 7 48.I have received written instructions from a doctor on when I can to return to school after having a concussion.(Note: Select N/A if you have not had a concussion) 1 2 3 4 5 6 7 N/A THANK YOU FOR COMPLETING THIS QUESTIONNAIRE If#you#have#any#questions#or#concerns#please#contact,#Amanda#Black#at#[email protected].

Player Questionnaire v.4 _09.24.2015 Page 4 of 4

184 Appendix F Concussion Knowledge Beliefs and Behaviour Questionnaire (CKBBQ): Parent and Coach Version

Child SSID______*office use only Team Number______Concussion Knowledge, Beliefs and Behaviour Questionnaire: Parents and Coaches Demographic Information Parent Name: Child's Name: My relationship to the player is: Mom Dad ______Team Name: What year were you born? ______Region: Calgary Vancouver Highest Level of Education: Some grade school High School Edmonton

Bachelor’s degree Graduate degree College Other______Date Completed: (mm/dd/yyyy) Part 1 1. How many years have you been a hockey parent? First year 1 2 3 4 5 6 7 >7 2. How many children do you currently have playing hockey? 0 1 2 3 4 5 6 >6 3. What levels of play are your child(ren) currently participating in? Timbit Atom (Division:___) Midget (Division:____) Varsity Tyke Pee Wee (Division:___) Junior (Division:____) Professional Novice (Division:___) Bantam (Division:____) Adult 4. (a) Have you ever coached hockey before? No Yes (Please indicate all levels coached) Timbit Atom (Divisions:____) Midget (Divisions:____) Varsity Tyke Pee Wee (Divisions:_____) Junior (Divisions:____) Professional Novice (Divisions:___) Bantam (Divisions:____) Adult (b) What is the highest division you have ever coached? 5. Do you have medical or first aid certification? No Yes (Please Describe) ______6. Have you completed the Hockey Canada Safety Program? No Yes I don't know 7. (a) Do you have experience playing hockey? No Yes, I currently play Yes, I used to play (b) How many years in total have you played? ______(c) What is the highest level you played? 8. Is being educated about concussion mandatory for parents in your association? No Yes I don't know 9. (a) How many concussions have all your children had in total? 0 1 2 3 4 5 6 >6 (b) If they have had a concussion think about the most severe concussion, how long did they take to recover? N/A It took them ______days to recover 10. (a) Have you ever received information about concussion? No Yes (b) Was the information provided to you this season? No Yes 11. Where do you get your information about concussion and how helpful is it? Do you get information If yes, how helpful is the information you receive? from the following Not at all Extremely places? helpful A little Somewhat Very helpful Hockey Association No Yes 1 2 3 4 5 Workshops/Coaching Clinics No Yes 1 2 3 4 5 Research Articles No Yes 1 2 3 4 5 TV No Yes 1 2 3 4 5 Newspapers No Yes 1 2 3 4 5 Social media No Yes 1 2 3 4 5 (Facebook, twitter) Magazines No Yes 1 2 3 4 5 Internet No Yes 1 2 3 4 5 Health Care Professionals No Yes 1 2 3 4 5 Other Parents No Yes 1 2 3 4 5 Other: ______No Yes 1 2 3 4 5

CKBBQ Parent version 4 (09/08/2015) Page 1 of 6

185 12. Who would you like to get information about concussions from? (Please check all that apply) Coaches The Hockey Association Other______Online Workshops Medical Doctors In person training Health Care Professionals 13. Have you completed the Concussion Awareness Training Tool? No No, and I don't know what that is Yes If yes: when did you complete it?______(dd/mm/yyyy) I heard about it from: A member of this research study Another parent A coach Other______14. Are you interested in being educated about concussion? No Yes Part 2 Please answer the following True or False questions to the best of your ability. Please mark T for true, F for false and ? if you don't know. 1. People who have had one concussion are more likely to have another concussion. T F ? 2. Sometimes a second concussion can help a person remember things that were forgotten after the first concussion. T F ? 3. An athlete can return to play while experiencing symptoms of a concussion if directed to do so by an athletic trainer or a physician. T F ? 4. There are helmets that prevent all concussions. T F ? 5. A concussion is a brain injury. T F ? 6. Have you heard of the term “graduated return to play protocol” or "stepwise return to play" for concussion? YES NO 6. a) If yes, can you try to list the 6 stages? Stage 1 ______Stage 2 ______Stage 3 ______Stage 4 ______Stage 5 ______Stage 6 ______In the following scenarios what is the most appropriate response: Do Nothing (DN), Non-Urgent: Book an appointment with doctor (NU), Urgent: Call 911/Take to Emergency (ED). 7. After a collision, body check, or fall your child starts vomiting repeatedly. DN NU ED 8. After a collision, body check, or fall your child has a headache that continues to get worse. DN NU ED 9. Immediately after a collision, body check, or fall your child immediately complains of a headache and dizziness but starts to feel better by the end of the game. DN NU ED Please answer the following True or False questions to the best of your ability. Please mark T for True, F for False and ? If you don't know. 10. In order to be diagnosed with a concussion, you have to be knocked out. T F ? 11. There is a higher risk of long term problems if someone has a second concussion before recovering from the first one. T F ? 12. Concussions can sometimes lead to emotional problems. T F ? 13. Ice hockey is a game typically played with a puck. T F ? 14. A concussion can only occur if there is a direct hit to the head. T F ? 15. There are few risks to long-term health and well-being from multiple concussions. T F ? 16. Younger players (under the age of 18) typically take longer to recover from a concussion than adults. T F ? 17. Post concussion symptoms can be delayed for hours or days. T F ?

CKBBQ Parent version 4 (09/08/2015) Page 2 of 6

186 Think about someone who has had a concussion. Select Y for the following signs and symptoms that you believe someone may be likely to experience BECAUSE of a concussion, N for symptoms not associated with concussion and ? If you don't know. 18. Hives Y N ? 24. Panic Attacks Y N ? 30. Excessive Studying Y N ? 31. Difficulty 19. Headache Y N ? 25. Feeling Tired Y N ? Concentrating Y N ? 20. Fever Y N ? 26. Feeling in a Fog Y N ? 32. Dizziness Y N ? 21. Arthritis Y N ? 27. Weight Gain Y N ? 33. Hair Loss Y N ? 22. Sensitivity to 28. Feeling Slowed Light Y N ? Down Y N ? 23. Difficulty 29. Reduced Breathing Remembering Y N ? Rate Y N ? Part 3 Please rate the following from 1 Not at all Likely to 7 Extremely Likely. 1 Not at all Likely -- 4 Moderately Likely -- 7 Extremely Likely 1. How likely is it that your child will sustain a concussion playing ice hockey? 1 2 3 4 5 6 7 2. How likely is it that your child will have long lasting consequences following a concussion in ice hockey? 1 2 3 4 5 6 7 Please rate the following from 1 Not at all Bad to 7 Extremely Bad. 1 Not at all bad -- 4 Moderately Bad -- 7 Extremely Bad 3-6. How bad is it for your child's health… 3. .. to not be assessed and cleared by a physician before returning to play after sustaining a suspected concussion? 1 2 3 4 5 6 7 4. .. to have a headache after a hard fall, collision, or body check and not be assessed and cleared by a physician before returning to play? 1 2 3 4 5 6 7 5. .. to be unsteady on their feet after a hard fall, collision, or body check and not be assessed and cleared by a physician before returning to play? 1 2 3 4 5 6 7 6. .. to feel dizziness after a hard fall, collision, or body check and not be assessed and cleared by a physician before returning to play? 1 2 3 4 5 6 7 Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 7-14. If I make my child see a physician for an assessment and they stay out of hockey and other activities until they get clearance from a physician after a suspected concussion… 7. ..It will reduce the chances of my child sustaining another concussion. 1 2 3 4 5 6 7 8. ..I will be wasting the money I spent on my child to play hockey. 1 2 3 4 5 6 7 9. ..It will reduce my child’s chance of making their injury worse and missing more hockey. 1 2 3 4 5 6 7 10. ..My child will be angry with me. 1 2 3 4 5 6 7 11. ..My child will lose their spot on the team. 1 2 3 4 5 6 7 12. ..It will help my child stay healthy. 1 2 3 4 5 6 7 13. ..I will miss too much work. 1 2 3 4 5 6 7 14. ..The doctor will not tell me anything new. 1 2 3 4 5 6 7 15-16. I am confident … 15. ..I can get my child to an appointment with a physician for a suspected concussion if needed. 1 2 3 4 5 6 7 16. ..I can make the decision of when to have my child see a physician for a suspected concussion if needed. 1 2 3 4 5 6 7 17. I intend to take my child to see a physician for an assessment if a concussion is suspected. 1 2 3 4 5 6 7 18. I intend to get a doctor’s clearance before allowing my child to return to activities following concussion. 1 2 3 4 5 6 7

CKBBQ Parent version 4 (09/08/2015) Page 3 of 6

187 Please rate the following from 1 Strongly Disagree to 7 Strongly Agree. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 19-21. I am confident that I can make sure my child gets evaluated and cleared by a doctor following concussion… 19. ..even if there is somewhere else I have to be. 1 2 3 4 5 6 7 20. ..even if my child doesn’t want to go to the appointment. 1 2 3 4 5 6 7 21. ..even if it’s playoff season. 1 2 3 4 5 6 7 22-23. I am confident that I can make sure my child gets evaluated and cleared by a doctor following concussion… 22. ..even if my child misses their first appointment because of a shift in schedules. 1 2 3 4 5 6 7 23. ..even if my child has played a few practices since the incident. 1 2 3 4 5 6 7 24. I have made plans that include how I can get my child in to see a physician if they sustain a concussion. 1 2 3 4 5 6 7 25. I have made plans about who my child will see if they sustain a concussion. 1 2 3 4 5 6 7 Please answer the following questions to the best of your ability. 26. Over the course the last hockey season (2014-2015) did you, your child, or your child's coach suspect that your child may have had a concussion in ice hockey? YES NO If the answer to question 26 was no please skip to question 30 27. If yes, how many times was a concussion suspected? 28. Of the times a concussion was suspected, how many times did you see a physician for an initial assessment and diagnosis? 29. Of the times a concussion was suspected, how many times did you see a physician for clearance to return to hockey? If the answer to question 26 was no continue here 30. Have you ever educated your child about concussions? Yes No No, but someone else educated them If yes, please check off the selections that best describes the education you provided. One-on-one session no resources: Signs and Symptoms Importance of reporting symptoms Enforce safe play One-on-one session with resources: Signs and Symptoms Importance of reporting symptoms Enforce safe play Other: ______31. In the last year, have you educated your child about concussion? YES NO 32. Do you plan to educate your child about concussions? YES NO 33. Do you have the resources you need to educate your child about concussions? YES NO Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 34. Teaching players to respect themselves and other players is essential for concussion prevention. 1 2 3 4 5 6 7 35-37. The 2013 rule change by Hockey Canada delaying the introduction of body checking until Bantam.. 35. … was effective at reducing concussion in Pee Wee. 1 2 3 4 5 6 7 36. ... led and will continue to lead to more concussions when players are allowed to check in Bantam. 1 2 3 4 5 6 7 37. … led and will continue to lead to more concussions when players are allowed to check in Midget. 1 2 3 4 5 6 7 38. Parents of elite ice hockey players are more likely than parents of non-elite players to want their child to return to play sooner following a concussion. 1 2 3 4 5 6 7 39. If my child has concussion-like symptoms after a rough hockey game but feels better by the time they get home I probably wouldn't take them to see a doctor. 1 2 3 4 5 6 7 40. I know ice hockey has many benefits for my child but sometimes the risk of concussion in the sport has me second guessing whether to enrol my child in the sport. 1 2 3 4 5 6 7 41. The risk of concussion in hockey cannot be reduced, it's just part of the game. 1 2 3 4 5 6 7 Open Comments?

IF YOU ARE NOT A COACH OR SAFETY DESIGNATE YOU HAVE NOW COMPLETED THE QUESTIONNAIRE THANK YOU FOR YOUR CONTRIBUTION TO RESEARCH If you have any questions or concerns please contact, Amanda Black at [email protected] CKBBQ Parent version 4 (09/08/2015) Page 4 of 6

188 Concussion Knowledge, Beliefs and Behaviour Questionnaire: Coach and Safety Designate Section Please complete this section only if you are coaching a Bantam or Midget team during the 2015-2016 hockey season or if you are the safety designate for a Bantam or Midget team during the 2015-2016 hockey season. Coach Demographic Information I am a: Head Coach Assistant Coach Safety Coach 1. How many years have you been a hockey coach (safety designate)? 2. What is your highest level of coaching certification? ______3. Which gender(s) have you coached in hockey? Female only Both female and male teams Male only Mixed gender teams 4. This season do you have access to any medical professionals to help manage injuries on the bench? (Check all that apply) No Access Athletic Therapist Physiotherapist Doctor Paramedic Other______5. Is being educated about concussion mandatory for coaches in your association? No Yes I don't know 6. How many concussions occurred last season on teams you were coaching? ______7. How many concussions on average do you see each season per team coached? ______8. In your role of coach, approximately how many concussions have you ever witnessed? ______Part 4 Please rate the following from 1 Not at all Likely to 7 Extremely Likely 1 Not at all Likely -- 4 Somewhat Likely -- 7 Extremely Likely 1. How likely is it that one of the players on your team will sustain a concussion this season? 1 2 3 4 5 6 7 2. How likely is it that one of the players on your team will have long lasting consequences following a concussion? 1 2 3 4 5 6 7 3. How likely are negative health consequences if an athlete is allowed to continue to play in the same game or practice in which he/she sustains a suspected concussion? 1 2 3 4 5 6 7 Please rate the following from 1 Not at all bad to 7 Extremely Bad 1 Not at all bad -- 4 Moderately Bad -- 7 Extremely Bad 4-7. How bad is it for a player's recovery… 4. .. to have symptoms of concussion but continue playing? 1 2 3 4 5 6 7 5. .. to have a headache after a hard fall, collision, or body check and continue playing? 1 2 3 4 5 6 7 6. .. to be unsteady on his/her feet after a hard fall, collision, or body check and continue playing? 1 2 3 4 5 6 7 7. .. to get dizzy after a hard fall, collision, or body check and keep playing? 1 2 3 4 5 6 7 Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 8-13. If I take one of my players out of a game or practice because I suspect they may have a concussion… 8. ..it would reduce the chances of the player sustaining another concussion. 1 2 3 4 5 6 7 9. ..my team would lose the game. 1 2 3 4 5 6 7 10. ..it would reduce the player’s chance of making their injury worse. 1 2 3 4 5 6 7 11. ..the parent of the player would be angry their child is not playing. 1 2 3 4 5 6 7 12. ..the parent of the player would question my decision. 1 2 3 4 5 6 7 13. ..it would help the player recover more quickly. 1 2 3 4 5 6 7 14-16. I am confident… 14. ..I can tell if one of my players should be removed from the game following a hard fall, collision, or body check. 1 2 3 4 5 6 7 15. ..I can make the decision to remove the player from play. 1 2 3 4 5 6 7 16. ..I can stop any of my players from playing should a concussion be suspected. 1 2 3 4 5 6 7 17. I intend to remove the player from play if a possible mechanism of concussion occurs. 1 2 3 4 5 6 7 18. I intend to remove the player from practice if a possible mechanism of concussion occurs. 1 2 3 4 5 6 7 19-21. I am confident I can make the decision to remove a player with a suspected concussion from play… 19. ..even if it is a playoff game. 1 2 3 4 5 6 7 20. ..even when the parent of the player gets upset with me. 1 2 3 4 5 6 7 21. ..even when the player tells me they are fine to play. 1 2 3 4 5 6 7

CKBBQ Parent version 4 (09/08/2015) Page 5 of 6

189 Please rate the following from 1 Strongly Disagree to 7 Strongly Agree 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 22-23. In spite of good intentions, it can be difficult to always make the right decision about when to remove a player from a game or practice if there is a possible concussion. 22. I am confident I can remove an athlete from the game if a concussion is suspected, even if it has been a few shifts since the incident occurred. 1 2 3 4 5 6 7 23. I am confident I can remove an athlete from the roster if a concussion is suspected, even if it they were allowed to finish playing the previous game. 1 2 3 4 5 6 7 24. Our team has standardized procedures for removing an athlete from play if a concussion is suspected. 1 2 3 4 5 6 7 25. Our team has a protocol in place that outlines how to manage concussions. 1 2 3 4 5 6 7

Please give the best response for the following questions. 26. Over the course of the last hockey season (2014-2015) did you suspect one or more of your players may have sustained a concussion in ice hockey? YES NO If the answer to question 26 was no please skip to question 30 27. If yes, how many times was a concussion suspected? 28. Of the times a concussion was suspected, how many times was the player removed from play immediately after the incident? 29. Of the times a concussion was suspected, how many times did the player continue playing before being removed? If the answer to question 26 was no continue here

Please report the number of times the following occurred after a hard fall, collision or body check during the last hockey season (2014-2015). 30. A player had headache or dizziness and finished the game or practice? 31. A player lost consciousness and finished the game or practice? 32. A player seemed forgetful and finished the game or practice? 33. Have you ever educated your players about concussions? YES NO If yes, please select all the mediums you used to educate: Fact Sheets Concussion Booklet Video/DVD Concussion Posters Presentation by you Presentation by "an expert". Decribe: ______Other: ______34. (a) In the last year have you educated your players about concussion? YES NO (b) Do you plan to educate your players about concussions this season? YES NO N/A 35. Do you have the resources you need to educate your players? YES NO 36. Have you ever educated the parents of your players about concussions? YES NO If yes, can you please describe the type of education you provided:

37. (a) Do you teach body checking skills to your players? YES NO (b) If yes, do you follow the modules provided by Hockey Canada? YES NO 38. Do you believe the following things prevent concussions? Improving neck strength YES NO I don't know Using a mouthguard YES NO I don't know Regulation Equipment (ex. CSA Helmet) YES NO I don't know

Open Comments?

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE If#you#have#any#questions#or#concerns#please#contact,#Amanda#Black#at#[email protected].

CKBBQ Parent version 4 (09/08/2015) Page 6 of 6

190 Appendix G Concussion Knowledge Beliefs and Behaviour Questionnaire (CKBBQ): Coach (Non-Parent) Version

Coach SSID______*office use only Team Number______Concussion Knowledge, Beliefs and Behaviour Questionnaire: Coach (non-parent) Please complete this questionnaire if you are coaching a Bantam or Midget team participating in the hockey study during the 2015-2016 hockey season or if you are the safety designate for a Bantam or Midget team during the 2015-2016 hockey season AND you do not have a child participating on the team. Demographic Information Coach Name: I am a: Head Coach Assistant Coach Safety Coach/Trainer Team Name: What year were you born? ______Region: Calgary Vancouver Highest Level of Education: Some grade school High School Edmonton Bachelor’s degree Graduate degree College Other______Date Completed: (mm/dd/yyyy) Part 1 1. How many years have you been a hockey coach (safety coach/Trainer)? 2. What is your highest level of coaching certification? ______3. Which gender(s) have you coached in hockey? Female only Male only Both female and male teams Mixed gender teams 4. (a) What levels of play have you coached? [Please select all the levels that apply to you and fill in the corresponding division(s)] Timbit Atom (Divisions:____) Midget (Divisions:____) Varsity Tyke Pee Wee (Divisions:_____) Junior (Divisions:____) Professional Novice (Divisions:___) Bantam (Divisions:____) Adult (b) What is the highest division you have ever coached? 5. Do you have medical or first aid certification? No Yes (Please Describe) ______6. Have you completed the Hockey Canada Safety Program? No Yes I don't know 7. This season do you have access to any medical professionals to help manage injuries on the bench? (Check all that apply) No Access Athletic Therapist Physiotherapist Doctor Paramedic Other______8. (a) Do you have experience playing hockey? No Yes, I currently play Yes, I used to play (b) How many years in total have you played? ______(c) What is the highest level you played? 9. (a) Have you ever received information about concussion? No Yes (b) Was the information provided to you this season? No Yes 10. Where do you get your information about concussion and how helpful is it? Do you get information If yes, how helpful is the information you receive? from the following Not at all Extremely places? helpful A little Somewhat Very helpful Hockey Association No Yes 1 2 3 4 5 Workshops/Coaching Clinics No Yes 1 2 3 4 5 Research Articles No Yes 1 2 3 4 5 TV No Yes 1 2 3 4 5 Newspapers No Yes 1 2 3 4 5 Social media No Yes 1 2 3 4 5 (Facebook, twitter) Magazines No Yes 1 2 3 4 5 Internet No Yes 1 2 3 4 5 Health Care Professionals No Yes 1 2 3 4 5 Other Parents No Yes 1 2 3 4 5 Other: ______No Yes 1 2 3 4 5 11. Is being educated about concussion mandatory for coaches in your association? No Yes I don't know 12. Is being educated about concussion mandatory for parents in your association? No Yes I don't know CKBBQ Non-Parent Coach v.4 (09/08/2015) Page 1 of 4

191 13. How many concussions occurred last season on teams you were coaching? ______14. How many concussions on average do you see each season per team coached? ______15. (a) In your role of coach, approximately how many concussions have you ever witnessed? ______(b) Think about the most severe concussion, how long did they take to recover? N/A It took them ______days to recover 16. Have you completed the Concussion Awareness Training Tool? No No, and I don't know what that is Yes If yes: when did you complete it?______(dd/mm/yyyy) I heard about it from: A member of this research study Another parent A coach Other______17. Are you interested in being educated about concussion? No Yes 18. Who would you like to get information about concussions from? (Please check all that apply) Coaching Clinics In person training Medical Doctors Other______Online Workshops The Hockey Association Health Care Professionals Part 2 Please answer the following True or False questions to the best of your ability. Please mark T for true, F for false and ? if you don't know. 1. People who have had one concussion are more likely to have another concussion. T F ? 2. Sometimes a second concussion can help a person remember things that were forgotten after the first concussion. T F ? 3. An athlete can return to play while experiencing symptoms of a concussion if directed to do so by an athletic trainer or a physician. T F ? 4. There are helmets that prevent all concussions. T F ? 5. A concussion is a brain injury. T F ? 6. Have you heard of the term “graduated return to play protocol” or "stepwise return to play" for concussion? YES NO 6. a) If yes, can you try to list the 6 stages? Stage 1 ______Stage 2 ______Stage 3 ______Stage 4 ______Stage 5 ______Stage 6 ______In the following scenarios what is the most appropriate response: Do Nothing (DN), Non-Urgent: Book an appointment with doctor (NU), Urgent: Call 911/Take to Emergency (ED). 7. After a collision, body check, or fall your child starts vomiting repeatedly. DN NU ED 8. After a collision, body check, or fall your child has a headache that continues to get worse. DN NU ED 9. Immediately after a collision, body check, or fall your child immediately complains of a headache and dizziness but starts to feel better by the end of the game. DN NU ED Please answer the following True or False questions to the best of your ability. Please mark T for true, F for false and ? if you don't know. 10. In order to be diagnosed with a concussion, you have to be knocked out. T F ? 11. There is a higher risk of long term problems if someone has a second concussion before recovering from the first one. T F ? 12. Concussions can sometimes lead to emotional problems. T F ? 13. Ice hockey is a game typically played with a puck. T F ? 14. A concussion can only occur if there is a direct hit to the head. T F ? 15. There are few risks to long-term health and well-being from multiple concussions. T F ? 16. Younger players (under the age of 18) typically take longer to recover from a concussion than adults. T F ? 17. Post concussion symptoms can be delayed for hours or days. T F ?

CKBBQ Non-Parent Coach v.4 (09/08/2015) Page 2 of 4

192 Think about someone who has had a concussion. Select Y for the following signs and symptoms that you believe someone may be likely to experience BECAUSE of a concussion, N for symptoms not associated with concussion and ? If you don't know. 18. Hives Y N ? 24. Panic Attacks Y N ? 30. Excessive Studying Y N ? 31. Difficulty 19. Headache Y N ? 25. Feeling Tired Y N ? Concentrating Y N ? 20. Fever Y N ? 26. Feeling in a Fog Y N ? 32. Dizziness Y N ? 21. Arthritis Y N ? 27. Weight Gain Y N ? 33. Hair Loss Y N ? 22. Sensitivity to Light Y N ? 28. Feeling Slowed Down Y N ? 23. Difficulty 29. Reduced Breathing Remembering Y N ? Rate Y N ? Part 3 Please rate the following from 1 Not at all Likely to 7 Extremely Likely 1 Not at all Likely -- 4 Somewhat Likely -- 7 Extremely Likely 1. How likely is it that one of the players on your team will sustain a concussion this season? 1""2""3""4""5""6""7" 2. How likely is it that one of the players on your team will have long lasting consequences following a concussion? 1""2""3""4""5""6""7" 3. How likely are negative health consequences if an athlete is allowed to continue to play in the same game or practice in which he/she sustains a suspected concussion? 1""2""3""4""5""6""7" Please rate the following from 1 Not at all bad to 7 Extremely Bad 1 Not at all bad -- 4 Moderately Bad -- 7 Extremely Bad 4-7. How bad is it for a player's recovery… 4. .. to have symptoms of concussion but continue playing? 1""2""3""4""5""6""7" 5. .. to have a headache after a hard fall, collision, or body check and continue playing? 1""2""3""4""5""6""7" 6. .. to be unsteady on his/her feet after a hard fall, collision, or body check and continue playing? 1""2""3""4""5""6""7" 7. .. to get dizzy after a hard fall, collision, or body check and keep playing? 1""2""3""4""5""6""7" Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 8-13. If I take one of my players out of a game or practice because I suspect they may have a concussion… 8. ..it would reduce the chances of the player sustaining another concussion. 1""2""3""4""5""6""7" 9. ..my team would lose the game. 1""2""3""4""5""6""7" 10. ..it would reduce the player’s chance of making their injury worse. 1""2""3""4""5""6""7" 11. ..the parent of the player would be angry their child is not playing. 1""2""3""4""5""6""7" 12. ..the parent of the player would question my decision. 1""2""3""4""5""6""7" 13. ..it would help the player recover more quickly. 1""2""3""4""5""6""7" 14-16. I am confident… 14. ..I can tell if one of my players should be removed from the game following a hard fall, collision, or body check. 1""2""3""4""5""6""7" 15. ..I can make the decision to remove the player from play. 1""2""3""4""5""6""7" 16. ..I can stop any of my players from playing should a concussion be suspected. 1""2""3""4""5""6""7" 17. I intend to remove the player from play if a possible mechanism of concussion occurs. 1""2""3""4""5""6""7" 18. I intend to remove the player from practice if a possible mechanism of concussion occurs. 1""2""3""4""5""6""7" 19-21. I am confident I can make the decision to remove a player with a suspected concussion from play… 19. ..even if it is a playoff game. 1""2""3""4""5""6""7" 20. ..even when the parent of the player gets upset with me. 1""2""3""4""5""6""7" 21. ..even when the player tells me they are fine to play. 1""2""3""4""5""6""7" 22-23. In spite of good intentions, it can be difficult to always make the right decision about when to remove a player from a game or practice if there is a possible concussion. 22. I am confident I can remove an athlete from the game if a concussion is suspected, even if it has been a few shifts since the incident occurred. 1""2""3""4""5""6""7" 23. I am confident I can remove an athlete from the roster if a concussion is suspected, even if it they were allowed to finish playing the previous game. 1""2""3""4""5""6""7"

CKBBQ Non-Parent Coach v.4 (09/08/2015) Page 3 of 4

193 Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 24. Our team has standardized procedures for removing an athlete from play if a concussion is suspected. 1""2""3""4""5""6""7" 25. Our team has a protocol in place that outlines how to manage concussions. 1""2""3""4""5""6""7" Please give your best response for the following questions. 26. Over the course of the last hockey season (2014-2015) did you suspect one or more of your players may have sustained a concussion in ice hockey? YES NO If the answer to question 26 was no please skip to question 30 27. If yes, how many times was a concussion suspected? 28. Of the times a concussion was suspected, how many times was the player removed from play immediately after the incident? 29. Of the times a concussion was suspected, how many times did the player continue playing before being removed? If the answer to question 26 was no continue here Please report the number of times the following occurred after a hard fall, collision or body check during the last hockey season (2014-2015). 30. A player had headache or dizziness and finished the game or practice? 31. A player lost consciousness and finished the game or practice? 32. A player seemed forgetful and finished the game or practice? 33. Have you ever educated your players about concussions? YES NO If yes, please select all the mediums you used to educate: Fact Sheets Concussion Booklet Video/DVD Concussion Posters Presentation by you Presentation by "an expert". Decribe: ______Other: ______34. (a) In the last year have you educated your players about concussion? YES NO 34. (b) Do you plan to educate your players about concussions this season? YES NO N/A 35. Do you have the resources you need to educate your players? YES NO 36. Have you ever educated the parents of your players about concussions? YES NO If yes, can you please describe the type of education you provided:

37. (a) Do you teach body checking skills to your players? YES NO 37. (b) If yes, do you follow the modules provided by Hockey Canada? YES NO 38. Do you believe the following things prevent concussions? Improving neck strength YES NO I don't know Using a mouthguard YES NO I don't know Regulation Equipment (ex. CSA Helmet) YES NO I don't know Please choose how much you disagree or agree with the following statements. 1 Strongly Disagree -- 4 Neutral -- 7 Strongly Agree 39. Teaching players to respect themselves and other players is essential for concussion prevention. 1 2 3 4 5 6 7 40-42. The 2013 rule change by Hockey Canada delaying the introduction of body checking until Bantam.. 40. … was effective at reducing concussion in Pee Wee. 1 2 3 4 5 6 7 41. ... led and will continue to lead to more concussions when players are allowed to check in Bantam. 1 2 3 4 5 6 7 42. … led and will continue to lead to more concussions when players are allowed to check in Midget. 1 2 3 4 5 6 7 43. Parents of elite ice hockey players are more likely than parents of non-elite players to want their child to return to play sooner following a concussion. 1 2 3 4 5 6 7 44. If my child has concussion-like symptoms after a rough hockey game but feels better by the time they get home I probably wouldn't take them to see a doctor. 1 2 3 4 5 6 7 45. I know ice hockey has many benefits for my child but sometimes the risk of concussion in the sport has me second guessing whether to enrol my child in the sport. 1 2 3 4 5 6 7 46. The risk of concussion in hockey cannot be reduced, it's just part of the game. 1 2 3 4 5 6 7 Open Comments?

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE If"you"have"any"questions"or"concerns"please"contact,"Amanda"Black"at"[email protected]. CKBBQ Non-Parent Coach v.4 (09/08/2015) Page 4 of 4

194 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

Appendix H Preseason Baseline Questionnaire SAFE TO PLAY HOCKEY STUDY

Preseason Baseline Questionnaire

Please complete this form before baseline testing and submit to your Team Designate. Study Subject You make seek help from a parent or guardian. ID# office use only

Name: / / Today's Date: Gender: Male Female Day Month Year

Age: City: Player's Phone No: ( )

Height: feet inches or cm / / Date of Birth: Weight: (lbs) or (kg) Day Month Year

Dominant Hand (for writing): Right Left Association:

Playing level: Pee Wee Bantom Midget

Division: 1 2 3 4 5 6 7 8 9 10 11

Position: Forward Defense Goalie Team Name:

Please check off how many years of organized hockey you have played prior to this season (check only one): 0 years 4 years 8 years 12 years 1 year 5 years 9 years 13 years 2 years 6 years 10 years 14 years 3 years 7 years 11 years Other:

EQUIPMENT (check all that apply) : a) Mouthguard: At games: always At practices: always less than 75% less than 75% never never

Type of mouthguard worn: Dentist customQfit off the shelf

b) Helmet: Make: Bauer CCM Itech Jofa Mission Nike RBK Other:

Type: full clear visor full wire cage combination visor/cage

Age: new this season new last season 2Q3 years old >3 years old

INJURY AND MEDICAL HISTORY: 1. Have you ever had a concussion or been "knocked out" or had your "bell rung"? Yes No

if "Yes", please list below0 Date: Activity at the time Time unconscious Memory loss (yes or no) Time loss before FULL return to sport

eg. (DD/MM/YY) hockey, skat eboarding, et c. 0min 30sec no 1 day, 10 days, et c

If you answered yes to Question 1, please indicate whether you have any persistent problems with: a) memory Yes No b) dizziness Yes No c) headaches Yes No

2. In the past 6 weeks, have you had an injury requiring medical attention AND at least 1 day of missed participation from physical activity? Yes No if "Yes", please describe this injury/these injuries to the best of your ability below0 Injury Date Injury Type Body Part Sport of Occurrence Treatment description Time loss before FULL return to sport eg. (DD/MM/YY) sprain, bruise , etc. knee, nose, et c. 42soc cer, wakeboarding, et c. first aid, physio, et c. 1 day, 3 weeks, et c

questionnaire continues

Safe To Play Pre-Season Questionnaire Page 1 of 4

195 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

196 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

197 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

SAFE TO PLAY HOCKEY STUDY

The following questions is for the study participant to complete.

These items ask about your thoughts to body checking and how you use body checking in hockey. We ask that you answer as honestly as possible without any influence from other people.

Please circle the numer that best matches your answer

Strongly Disagree Agree Strongly Disagree Alittle Neither Alittle Agree    1 2 3 4 5

1) I like body checking 1 2 3 4 5

2) I like to be body checked 1 2 3 4 5

3) My coach encourages me to body check 1 2 3 4 5

4) My parents encourage me to body check 1 2 3 4 5

5) My teammates encourage me to body check 1 2 3 4 5

6) I could be seriously injured by a body check 1 2 3 4 5 7) I could seriously injure someone else with a 1 2 3 4 5 body check 8) I think body checking increases my teams 1 2 3 4 5 chances of winning 9) I would try to harm an opponent with a body check if it would increase my teams chance of 1 2 3 4 5 winning 10) I think body checking should be allowed in 1 2 3 4 5 Pee Wee hockey 11) I would body check another player even if I 1 2 3 4 5 knew it would injure them. ! $$ ! $ ! $ ! $ $$ !$HeadachHeadache$History:$yourself$and$your$familye!History! .$ $ !$ Have$you$had/do$$ $ D$ o!you,!or!have!you!ever!had! ! Previous$headaches$ No$ Yes$ Unknown$ !! Previous$migraine$ Previous!headaches! No$ Yes$ Unknown$ No! Yes! Unknown! Parent/Sibling$with$headaches$$ Previous!migraines! No$ Yes$ Unknown$ No! Yes! Unknown! Parent/Sibling$with$migraine$ Parent/Sibling!with!headaches! No$ Yes$ Unknown$ No! Yes! Unknown! Parent/Sibling!with!migraine! No! Yes! Unknown! !! !!! Safe To Play Pre-Season Questionnaire Page 4 of 4 ! 45

198 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

Appendix I Weekly Exposure Sheet D I I y a

d / / R

S C P D I I y a d

r / / R u

S C P D I I y a

/ / R d i

C P D I I y a d

s / / R r

T : C : P D n I : o i m m s i D a a y v I i I e e a D T T d s

e / / R n

C e Y W P e D U h T S S D

I I Y e y E r a K

u d C / / s R s

e O

u H

p C Y x P A E L

y l D O I I T k

y E a e F

d e A / / R n

M C P , ) t e n ) m . e e n a c e t ) t m o g e

L e e f

p o , f W = t g # p m e o s n ) d o e y s g

i a a / e a a D o l n B P M L p

= m m

r , , ) a d T m e i s e e r

n = t : m

c e y r s t a e a

l i p u , a u g T l y o

g u r n , y n P n i ( i o D o n r

W s , m o a i = ( m P t G

n a s i d

e = r e n e c e t a W l i o

g t (

c u c

i y

, c g t A

e b

g e a

c r

r s i

. m a

n p r e

i e ) i o

e d t

( r a P t r r e t

r c

e r u

t t , e ) o e o o t d

n e l

) l ) e t )

o n l " y a u i u y p o i y h ) l p l o y m G d p k 0 l e % t i a r d b a e " s l e ) ) C e t # i

= o 5 u e a f M

m : r r o , r

i R ) r e k f r 0

p t m

% p

c n F e ( e o s g t i D e D n

o e e c y T y I y 5 y < e s t r a h t o

/ r t n r c a n ( t o " n

i m o i r e e l 7

m n

o t y O c t c s l g u l m u h P T o t r a a h j k j n o

( i " o a s t e

g a a

a a a f S N a t

t g u l a o n n c i c o

p e l j

I i i n n n n p e t e c e U s t i i o a e d i n i r o i

G n u e

N t

d # G s

I r e R n m o

( D

c p e F i h d a (

R M ( i d i r t a e n o n t e a e

P o

g i i t

n D P t f

& f c r e e i M e I n n 0 p y

d i

e i R o n e D l

i r m

l r k i ( F o t I ) e e t e h a

c ) I r o t o o u a p t P s c e u c e i i c y i j P j P o

m C i h r

t e n r a t e : a ( r s s N a t . m r m O n r S n P t m

r N r

I I o u s o s p

p e ( o u e e j ( a

a r a l s o f . a u C o i N e c e o I N S O

n f t P I p ( p a i ( c F D S S G D S (

199 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

Appendix J Injury Report Form

200 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

Injury Report Form Continued Page 2 Injury ID #:

15.a) Describe to the best of your ability the events surrounding the injury:

15.b) Please check off all that apply to describe the cause of the injury: Body Check if yes: delivered received Other Intentional Player Contact please specify: elbowing slashing crossQchecking tripping roughing head contact Incidental (unintentional) Contact with another player or their equipment Contact with the environment, NOT another player if yes: puck boards net No contact Unknown

16. Was there a penalty called directly related to the injury event? Yes No 16a) If yes, what was the penalty? (check all that apply) Body checking related Q Describe:______StickQrelated Q Describe:______Head contact related Q Describe:______Fighting Other, describe______16b) If yes, what was the consequence of the penalty? (check all that apply) penalty shot double minor 10 min misconduct match penalty 2 min minor 5 min major game misconduct suspension indicate length of suspension______16c) If yes, who received the penalty? (check all that apply) Injured player Injured player's teammate Opposing team player

17. Protective gear worn at the time of injury (check all that apply): Mouthguard Yes No Don't know if yes, specify: Dentist customQfit off the shelf Brace Yes No Don't know if yes, specify: Knee Ankle Other* *please describe: ______Tape Yes No Don't know if yes, specify: Knee Ankle Other* *please describe: ______Helmet make: Bauer CCM Itech Jofa Mission Nike RBK Other model (eg. Junior 652C, Jr Ignite 4, etc.): describe other0 type: full clear visor full wire cage combination visor/cage helmet age: new this season new last season 2Q3 yrs old >3 years old

201 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

Injury Report Form Continued Page 3 Injury ID #:

18. Injury Location (check all that apply, circle affected side where applicable): Head Throat Hand (L / R) Pelvis Ankle (L / R) Face Shoulder (L / R) Finger (L / R) Hip (L / R) Foot (L / R) Ears (L / R) Collarbone (L / R) Back Groin (L / R) Toes (L / R) Eye (L / R) Upper arm (L / R) Side (L / R) Genitals Other* Nose Elbow (L / R) Ribs (L / R) Upper Leg (L / R) Teeth Forearm (L / R) Chest Knee (L / R) Neck Wrist (L / R) Abdomen Lower leg (L / R)

19.Type of Injury (check all that apply to this injury): Bruise Cut Dislocation Knocked out Burn Blister Broken bone Concussion Bleeding Joint swelling Muscle strain Other, please Abrasion/Scrape Joint/ ligament sprain Tendonitis describe0

**Please do not complete questions 20 through 26 until the player has returned fully to competitive play and has completed all injuryBrelated care 20. Total number of calendar days the player was unable to participate in your normal activities of daily living: (i.e.. work, school, camp, other) 21. Total number of calendar days the player was unable to participate in any sport due to this injury:

22. Total number of calendar days the player was unable to participate in hockey:

23. Total number of days (or hours) the parent or guardian missed work as a direct result of the player's injury days hours 24. Did the player see any health care professional(s) for assessment or treatment of this injury? Yes No (if yes, please check all that apply once you have completed all care for this injury) Physician (Family) (Total # visits ) Massage therapist (Total # visits ) Physician (Specialist) (Total # visits ) Dentist (Total # visits ) specialty: Chiropractor (Total # visits ) Physiotherapist (Total # visits ) Other (Total # visits ) Athletic Therapist (Total # visits ) please specify0______

25. Did the player receive any other treatment for this injury? Yes No (if yes, please check all that apply. Be as specific as possible, including location of service provided) First Aid MRI/CT (# ) Cast (# ) Crutches Surgery Xrays (# ) bone scan (# ) Brace Taping Medications Other, please describe0

26. Who provided the player with clearance to return to activity? Self Parent Coach Therapist Physician Other, please describe0

202 CA Emery et al. Safe To Play Hockey Study Research Proposal Appendices

If the player is seen by a physician, physiotherapist, athletic therapist or other medical practitioner for this injury please have them complete one of the following sections: Upon completion, please return this form to your Team Designate

Safe To Play HOCKEY STUDY office use only Athlete's Name: IID UCDC

Date: / / Day Month Year

Attending Medical Prame: Occupation (i.e.. Family Physician/Specialist/Therapist/etc): Diagnosis:

Treatment Plan:

Expected/Recommended duration of treatment:

Is this athlete cleared to resume unrestricted competition? Yes No IF NO: Expected date of clearance: Conditions of clearance:

Does this athlete require medical follow up prior to clearance? Yes No

Safe To Play HOCKEY STUDY office use only Athlete's Name: IID UCDC

Date: / / Day Month Year

Attending Medical Prame: Occupation (i.e.. Family Physician/Specialist/Therapist/etc): Diagnosis:

Treatment Plan:

Expected/Recommended duration of treatment:

Is this athlete cleared to resume unrestricted competition? Yes No IF NO: Expected date of clearance: Conditions of clearance:

Does this athlete require medical follow up prior to clearance? Yes No

203 Appendix K Copyright Permission Letter

BMJ PUBLISHING GROUP LTD. LICENSE TERMS AND CONDITIONS Apr 27, 2017

This Agreement between Amanda M Black ("You") and BMJ Publishing Group Ltd. ("BMJ Publishing Group Ltd.") consists of your license details and the terms and conditions provided by BMJ Publishing Group Ltd. and Copyright Clearance Center.

License Number 4065700818341 License date Licensed Content Publisher BMJ Publishing Group Ltd. Licensed Content Publication British Journal of Sports Medicine Licensed Content Title The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada’s national body checking policy change Licensed Content Author Amanda M Black,Brent E Hagel,Luz Palacios-Derflingher,Kathryn J Schneider,Carolyn A Emery Licensed Content Date Mar 9, 2017

Type of Use Dissertation/Thesis Requestor type Author of this article

Format Print and electronic Portion Figure/table/extract

Number of 4 figure/table/extracts Descriptionof The manuscript is a chapter in my dissertation. Table 1 Table 2 Table figure/table/extracts 3 Figure 1 There are 3 print copies and an online copy. Will you be translating? No

Circulation/distribution 3 Title of your thesis / Prevention and management of concussions in youth ice hockey: dissertation Policy, Education, Beliefs and Behaviours

Expected completion date Jun 2017 Estimated size(pages) 200 Requestor Location Amanda M Black 2500 University Drive NW

Calgary, AB T2N1N4 Canada Attn: Amanda M Black

Publisher Tax ID GB674738491 Billing Type Invoice Billing Address Amanda M Black 2500 University Drive NW

204 Calgary, AB T2N1N4 Canada Attn: Amanda M Black Total 0.00 CAD Terms and Conditions BMJ Group Terms and Conditions for Permissions When you submit your orderyou are subject to the terms and conditions set out below. You will also haveagreed to the Copyright Clearance Center's ("CCC") terms and conditionsregarding billing and payment https://s100.copyright.com/App/PaymentTermsAndConditions.jsp. CCC are acting as the BMJ Publishing Group Limited's ("BMJ Group's") agent. Subject to the terms set outherein, the BMJ Group hereby grants to you (the Licensee) a non- exclusive,non-transferable licence to re-use material as detailed in your request forthis/those purpose(s) only and in accordance with the following conditions: 1) Scope of Licence: Useof the Licensed Material(s) is restricted to the ways specified by you duringthe order process and any additional use(s) outside of those specified in thatrequest, require a further grant of permission. 2) Acknowledgement: Inall cases, due acknowledgement to the original publication with permission fromthe BMJ Group should be stated adjacent to the reproduced Licensed Material.The format of such acknowledgement should read as follows: "Reproduced from [publicationtitle, author(s), volume number, page numbers, copyright notice year] withpermission from BMJ Publishing Group Ltd." 3) Third Party Material:BMJ Group acknowledges to the best of its knowledge, it has the rights to licenceyour reuse of the Licensed Material, subject always to the caveat thatimages/diagrams, tables and other illustrative material included within, whichhave a separate copyright notice, are presumed as excluded from the licence. Therefore,you should ensure that the Licensed Material you are requesting is original toBMJ Group and does not carry the copyright of another entity (as credited inthe published version). If the credit line on any part of the material you haverequested in any way indicates that it was reprinted or adapted by BMJ Groupwith permission from another source, then you should seek permission from thatsource directly to re-use the Licensed Material, as this is outside of thelicence granted herein. 4) Altering/ModifyingMaterial: The text of any material for which a licence is granted may notbe altered in any way without the prior express permission of the BMJ Group. Subject to Clause 3 above however, single figure adaptations do not require BMJGroup's approval; however, the adaptation should be credited as follows: "Adapted by permission fromBMJ Publishing Group Limited. [publication title, author, volume number, pagenumbers, copyright notice year] 5) Reservation of Rights:The BMJ Group reserves all rights not specifically granted in the combinationof (i) the licence details provided by you and accepted in the course of thislicensing transaction, (ii) these terms and conditions and (iii) CCC's Billing and Payment Terms and Conditions. 6) Timing of Use: Firstuse of the Licensed Material must take place within 12 months of the grant ofpermission. 7). Creation of Contractand Termination: Once you have submitted an order via Rightslink and thisis received by CCC, and subject to you completing accurate details of yourproposed use, this is when a binding contract is in effect and our acceptanceoccurs. As you are ordering rights from a periodical, to the fullest extentpermitted by law, you will have no right to cancel the contract from this pointother than for BMJ Group's material breach or fraudulent misrepresentation oras

205 otherwise permitted under a statutory right. Payment must be made inaccordance with CCC's Billing and Payment Terms and conditions. In the eventthat you breach any material condition of these terms and condition or any of CCC's Billing and Payment Terms and Conditions, the license is automatically terminated uponwritten notice from the BMJ Group or CCC or as otherwise provided for in CCC's Billing and Payment Terms and Conditions, where these apply.. Continued use of materials wherea licence has been terminated, as well as any use of the Licensed Materialsbeyond the scope of an unrevoked licence, may constitute intellectual propertyrights infringement and BMJ Group reserves the right to take any and all actionto protect its intellectual property rights in the Licensed Materials. 8. Warranties: BMJGroup makes no express or implied representations or warranties with respect tothe Licensed Material and to the fullest extent permitted by law this isprovided on an "as is" basis. For the avoidance of doubt BMJ Group does notwarrant that the Licensed Material is accurate or fit for any particularpurpose. 9. Limitation ofLiability: To the fullest extent permitted by law, the BMJ Group disclaimsall liability for any indirect, consequential or incidental damages (includingwithout limitation, damages for loss of profits, information or interruption)arising out of the use or inability to use the Licensed Material or theinability to obtain additional rights to use the Licensed Material. To thefullest extent permitted by law, the maximum aggregate liability of the BMJGroup for any claims, costs, proceedings and demands for direct losses causedby BMJ Group's breaches of its obligations herein shall be limited to twice theamount paid by you to CCC for the licence granted herein. 10. Indemnity: You hereby indemnify and holdharmless the BMJ Group and their respective officers, directors, employees andagents, from and against any and all claims, costs, proceeding or demands arisingout of your unauthorised use of the Licensed Material.

11. No Transfer of License: This licence ispersonal to you, and may not be assigned or transferred by you without priorwritten consent from the BMJ Group or its authorised agent(s). BMJ Groupmay assign or transfer any of its rights and obligations under this Agreement,upon written notice to you. 12. No Amendment Except inWriting: This licence may not be amended except in a writing signed by bothparties (or, in the case of BMJ Group, by CCC on the BMJ Group's behalf). 13. Objection to Contraryterms: BMJ Group hereby objects to any terms contained in any purchaseorder, acknowledgment, check endorsement or other writing prepared by you,which terms are inconsistent with these terms and conditions or CCC's Billing and Payment Terms and Conditions. These terms and conditions, together with CCC's Billing and Payment Terms and Conditions (which to the extent they are consistent areincorporated herein), comprise the entire agreement between you and BMJ Group (and CCC) and the Licensee concerning this licensing transaction. In the event ofany conflict between your obligations established by these terms and conditionsand those established by CCC's Billing and Payment Terms and Conditions, theseterms and conditions shall control. 14. Revocation: BMJGroup or CCC may, within 30 days of issuance of this licence, deny thepermissions described in this licence at their sole discretion, for any reasonor no reason, with a full refund payable to you should you have not been ableto exercise your rights in full. Notice of such denial will be made using thecontact information provided by you. Failure to receive such notice from BMJGroup or CCC will not, to the fullest extent permitted by law alter orinvalidate the denial. For the fullest extent permitted by law in no event willBMJ Group or CCC be responsible or liable for any costs, expenses or damageincurred by you as a result of a denial of your permission request, other thana refund of the amount(s) paid by you to BMJ Group and/or CCC for denied permissions.

206 15. Restrictions to thelicense: 15.1 Promotion: BMJ Group will not give permission to reproduce infull or in part any Licensed Material for use in the promotion of thefollowing: a) non-medical products thatare harmful or potentially harmful to health: alcohol, baby milks and/or, sunbeds b) medical products that donot have a product license granted by the Medicines and Healthcare productsRegulatory Agency (MHRA) or its international equivalents. Marketing of theproduct may start only after data sheets have been released to members of themedical profession and must conform to the marketing authorization contained inthe product license. 16. Translation: This permission is granted for non-exclusive worldEnglish language rights only unless explicitly stated in your licence. Iftranslation rights are granted, a professional translator should be employedand the content should be reproduced word for word preserving the integrity ofthe content. 17. General:Neither party shall be liable for failure, default or delay in performingits obligations under this Licence, caused by a Force Majeure event which shallinclude any act of God, war, or threatened war, act or threatened act ofterrorism, riot, strike, lockout, individual action, fire, flood, drought,tempest or other event beyond the reasonable control of either party.

17.1 Inthe event that any provision of this Agreement is held to be invalid, theremainder of the provisions shall continue in full force and effect.

17.2 Thereshall be no right whatsoever for any third party to enforce the terms andconditions of this Agreement. The Parties hereby expressly wish to exclude theoperation of the Contracts (Rights of Third Parties) Act 1999 and any otherlegislation which has this effect and is binding on this agreement.

17.3 Tothe fullest extent permitted by law, this Licence will be governed by the lawsof England and shall be governed and construed in accordance with the laws of England. Any action arising out of or relating to this agreement shall be brought in courtssituated in England save where it is necessary for BMJ Group for enforcement tobring proceedings to bring an action in an alternative jurisdiction.

Questions? [email protected] or +1-855-239-3415 (toll free in the US) or +1-978-646-2777.

207