Yes / ... Sustaining a sport-related concussion (SRC) has been associated with negative consequences to emotion and cognition in recent years,4,5 and head impacts are no different.1 Moreover, there is a consistent link reported with neurodegenerative diseases such as motor-neuron disease, Parkinson’s disease, and dementia. Although this is well-known within the scientific community, and becoming so in the general population, we still place children at risk. Promoting attitude change toward SRC and head impacts in sport is difficult enough with adults as many are accustomed to the way their contact sports are played and spectated. However, a redeeming feature for many researchers is that the evidence is there, and the rhetoric is being discussed in the mainstream media across the world.

The overarching purposes of this research were to (a) explore an under-acknowledged and under-emphasized aspect of the sport-related concussion experience: psychosocial factors of the injury experience and (b) identify possible intervention opportunities to support the associated psychological and social needs. A collaborative inquiry (Bray et al., 2000) was employed to generate data on the psychosocial experience of concussions in elite sport and to co-develop support strategies from a sport psychology lens. This qualitative research project involved three phases during which psychological and social needs, as well as psychosocial factors that facilitated and/or hindered the concussion recovery process, were discussed through two lenses. The first lens was an experiential one, whereby elite athletes who became concussed as a result of their sport engagement shared their experiences (Phase A). The second lens was that of professional expertise, whereby mental performance consultants who work in elite sport and deliver psychosocial support to concussed elite athletes shared their perspectives and clients’ experiences (Phase B). Following the sharing of these perspectives, a community of practice (Wenger et al., 2002) of mental performance consultants was formed to collaboratively discuss how mental performance consultants might be able to support the aforementioned psychological and social needs, and ultimately, concussion recovery (Phase C). Phase A. Ten elite athletes (as defined by Swann et al., 2015) participated in semi-structured focus groups (Smith & Sparkes, 2016). Athletes discussed their experiences of injury, challenges, facilitators and barriers to recovery, support mechanisms, support that was lacking but desired, and what they would do to help someone else with a concussion. The transcripts from these focus groups (n = 5, M = 58.1 min, Range: 46-88 min), follow-up questions, and informal conversations were analyzed using thematic narrative analysis (Smith, 2016), contributing to an understanding of the athletes’ lived experiences. Phase B. Nine mental performance consultants from the Canadian Sport Psychology Association and/or Association for Applied Sport Psychology who were working in high-performance sport participated in three focus groups (M = 79 min, Range = 66-98 min). Mental performance consultants were asked about their time in the field and other aspects of their consulting experience (e.g., sports, integrated within teams or not), the types of interventions they have done with concussed athletes, their perceptions of psychosocial support during the phases of concussion management, and challenges to effective service delivery. Verbatim transcripts of these focus groups were sent to the consultants and member reflections were requested (Smith & McGannon, 2018). The generated data were thematically analyzed using a six-phase cyclical and iterative approach (Braun et al., 2016). Phase C. Eight mental performance consultants from various sport contexts formed a community of practice (Wenger et al., 2002; E. Wenger-Trayner & Wenger-Trayner, 2021). The group met over a period of four months (n = 8 meetings, M = 80 min, Range = 60-90 min). These meetings were intended to address the identified interests of the members of the community regarding support for concussed elite athletes. Concussion symptomatology, management efforts, and research were discussed; and professional scope of practice and intervention opportunities were explored through best practice discussions, client case studies, and engagements with two external experts. Mental performance consultants completed individual reflections (i.e., weekly reflective questions, value creation stories, personal value narratives; Wenger et al., 2011; E. Wenger-Trayner & Wenger-Trayner, 2015) resulting in 34 single-spaced pages of generated data, which were analyzed using the Value Creation Framework (E. Wenger-Trayner & Wenger-Trayner, 2015; 2021). The results of this multi-phase collaborative inquiry are presented in four articles. The first article offers a multi-systems perspective (Bronfenbrenner, 1977; 1979; 1992) on athletes’ concussion experiences by exploring two collaboratively created narratives (Wertz, 2011; Willis, 2019) from the engagements with athletes in Phase A. Five themes (i.e., athletic identity, (dis)trust in relationships, concussion protocols, sport culture, and timing related to major events and recovery) are discussed. The second article combines the perspectives of athletes from Phase A and mental performance consultants in Phase B to identify psychological and social needs across the concussion recovery process. Four psychological needs (i.e., acceptance, normality, confidence, self-efficacy) and two social needs (i.e., trust in relationships, social support) were identified by both populations. The third article was collaboratively written to practically present how and where mental performance consultants can support concussed athletes across the phases of the injury based on the discussions in Phase C. Scope of practice, collaboration opportunities, and intervention strategies are discussed across four phases of injury (i.e., pre-injury, injury onset, rehabilitation, return to sport). The fourth article reflects the mental performance consultants’ participatory experiences in Phase C by exploring the value of the community of practice as a professional development and knowledge translation tool. Positive value was experienced across all eight cycles of the Value Creation Framework. Through the general discussion and practical implications sections of this dissertation, these results are situated within the landscapes of concussion research and practice to highlight opportunities for transforming concussion protocols and broadening the overall lens through which the concussion experience can be examined.

The research presented herein is a combination of work done in two distinct subcategories of sport related head injury research. The body of work is aimed at increasing the understanding of head impact biomechanics across a broad spectrum of impact scenarios as well as the ability of helmets to affect head impact biomechanics over time. The first study utilizes in situ testing of controlled impacts of an instrumented head form to more fully characterize head accelerations resulting from impacts to the ice, board, and glass surfaces present in an ice hockey rink. The full characterization of head impacts across a spectrum of loading conditions and impact surfaces gives researchers insight into head impact tolerance and head protection capabilities and limitations in ice hockey. The second study details the development of a method to impact helmet pads for repeated loading studies based on published head impact exposure data. The third study uses this newly developed methodology to test the effects of a season of impacts on the energy absorbing properties of three different helmet padding technologies. The body of work is aimed at increasing understanding of head impact and concussion and the ability of existing helmet technologies to prevent these injuries with a goal of reducing the occurrence of injury. / Master of Science

Objective: Following a sport related concussion (SRC) visible symptoms generally dissipate in 7-10 days post-injury. However, little is known about the cumulative effects of SRCs both in terms of structural damage to the white matter of the brain and neurocognitive performance. To address this issue, the relationship between the number of SRCs (frequency), axonal white matter (WM) damage and neurocognitive performance was examined. There were three predictions. First, increases in SRC frequency will be associated with decreases in performance on neurocognitive tests. Second, the frequency of SRC will be associated with axonal injury measured three WM tracts: the corpus callosum, the fronto-occipital fasciculus and the inferior longitudinal fasciculus. Third, less accurate and slower performance on a response inhibition task (STOP-IT) will be associated with greater axonal injury. Methods: A cross-sectional correlational design was utilised. Participants were rugby players with a history of SRC, rugby players with no history of SRC and control athletes (N=40) who completed a neurocognitive test battery and had a DTI brain scan. The neurocognitive battery consisted of the following standardised tests: Speed and Capacity of Language Processing Test, CogState Electronic Battery, Stroop Colour and Word Test, Controlled Oral Word Association Test, the Trail Making Test and the experimental test STOP-IT Electronic Test. White matter axonal injury was measured by DTI using fractional anisotropy (FA) and mean diffusivity (MD) metrics. The DTI data was processed using FSL to extract FA and MD DTI metrics in three a-priori regions of interest. Results: Spearman’s correlation analyses did not find significant associations between SRC frequency and neurocognitive performance on the FAS (rs=0.053, 95% CI [-0.27, 0.36]), TMT-A (rs=0.058, 95% CI [-0.26, 0.37]), TMT-B (rs= -0.046, 95% CI [-0.27, 0.36]) and the Stroop Interference (rs= -0.25, 95% CI [-0.07, 0.52]). Similarly, no significant Spearman’s correlations were found between SRC frequency and the computerised neurocognitive tests STOP-IT-SSRT (rs= -0.04, 95% CI [-0.28, 0.35])), STOP-IT–Accuracy (rs= -0.05, 95% CI [-0.27, 0.36]), CogState Detection subtest (rs= -0.15, 95% CI [-0.17, 0.44]), CogState Identification subtest (rs= -0.065, 95% CI [-0.26, 0.37]), CogState One card learning subtest (rs= 0.24, 95% CI [-0.08, 0.52]) or the CogState One back task subtest (rs= 0.06, 95% CI [-0.26, 0.37]). In terms of the DTI data there were no significant associations between SRC frequency and axonal injury measured by FA values in the CC (rs= 0.005, 95% CI [-0.31, 0.32]), ILF (rs= 0.028, 95% CI [-0.29, 0.34]) or FOF (rs= -0.022, 95% CI [-0.30, 0.33]). The same was pattern was found for MD values in the CC (rs= 0.081, 95% CI [-0.24, 0.39]), ILF (rs= -0.16, 95% CI [-0.16, 0.45]) or FOF (rs= -0.15, 95% CI [-0.17, 0.44]) Finally, there were no significant Spearman’s correlations between axonal injury FA values and the STOP-IT SSRT in any of the ROIs: CC (rs= 0.005, 95% CI [-0.31, 0.32]), ILF (rs= 0.028, 95% CI [-0.29, 0.34]) or FOF (rs= -0.022, 95% CI [-0.30, 0.33]). Equally, there were no significant correlations between MD values STOP-IT SSRT in the CC (rs= -0.028, 95% CI [-0.29, 0.34]), ILF (rs= -0.16, 95% CI [-0.16, 0.45]) or FOF (rs= -0.15, 95% CI [-0.17, 0.44]). Likewise, there were no significant Spearman’s correlations between accuracy on the STOP-IT and FA values and in any of the ROIs: CC (rs= 0.19, 95% CI [-0.13, 0.48]), ILF (rs= -0.045, 95% CI [-0.27, 0.35]) and FOF (rs= -0.032, 95% CI [-0.29, 0.34]), or MD values in the CC (rs= -0.11, 95% CI [-0.21, 0.41]), ILF (rs= 0.017, 95% CI [-0.30, 0.33]) or FOF (rs= 0.082, 95% CI [-0.24, 0.39]). This study did not find support for the hypothesis that cumulative SRCs are associated with poorer performance on neurocognitive tests or with axonal injury as measured by FA and MD DTI metrics. Conclusion: The null findings suggest that there are no cumulative effects of SRCs. The current findings are inconsistent with previous cross-sectional research that indicates that there are long-term changes to diffusivity measures present after single SRCs as well as cumulative effects in contact sport athletes. Likewise they are at odds with evidence suggesting that after three SRCs neurocognitive performance can be affected. The study needs to be extended to include a larger sample to ensure the results are not due to low statistical power.

Sports-related concussions are a growing public health concern affecting numerous varsity football student-athletes. This study used the social ecological model to identify intrapersonal, interpersonal, and environmental factors. The purpose of this study is to identify constraints and facilitators in academic and athletic settings for varsity football student-athletes with a sport-related concussion. Twelve current varsity football student-athletes from one institution who suffered a sport-related concussion took part in semi-structured interviews. Data were thematically analyzed. Results indicate that varsity football student-athletes with a sport-related concussion perceived numerous constraining and facilitating social ecological factors in the academic and athletic settings. Intrapersonal constraints revolved around loss of motivation, loss of social identification, stress, anxiety and depression, injury-specific issues (i.e. difficulty thinking clearly, remembering, drowsiness), internal pressure to return, while intrapersonal facilitators included prior experiences of enjoyment in academic and athletic activities, seeing improvements in the recovery process, and not giving up. Interpersonal constraints related to insufficient social support, lack of awareness and guidance on concussion knowledge, external pressure to return, and lack of academic support post-concussion, while interpersonal facilitators included passionate therapy staff, and sport psychologist. Environmental constraints pertained to return-to-play and return-to-learn protocols, while environmental facilitators included having access to concussion-based resources. Findings suggest that there remains a need to address constraining and facilitating factors in the academic and athletic settings for varsity football student-athletes with a sport-related concussion

Background: Vestibular dysfunction, characterized by nausea, dizziness, imbalance, and/or gait disturbance, represents an important sport-related concussion (SRC) subtype associated with prolonged recovery. Vestibular physical therapy promotes recovery; however, the benefit of earlier therapy is unclear. Hypothesis: Earlier vestibular therapy for young athletes with SRC is associated with earlier return to play (RTP), return to learn (RTL), and symptom resolution. Study Design: Retrospective cohort study. Level of Evidence: Level 3. Methods: Patients aged 5 to 23 years with SRC who initiated vestibular rehabilitation therapy (VRT) from January 2019 to December 2019 were included and patient records were reviewed. Therapy initiation was defined as either early, ≤30 days postinjury, or late (>30 days). Univariate comparisons between groups, Kaplan-Meier plots, and multivariate Cox proportional hazard modeling were performed. Results: Overall, 23 patients (10 early, 13 late) aged 16.14 ± 2.98 years and 43.5% were male patients. There was no difference between group demographics or medical history. Median initial total and vestibular symptom scores were comparable between groups. The late therapy group required additional time to RTP (110 days [61.3, 150.8] vs 31 days [22.5, 74.5], P = 0.03) and to achieve symptom resolution (121.5 days [71, 222.8] vs 54 days [27, 91], P = 0.02), but not to RTL (12 days [3.5, 26.5] vs 17.5 days [8, 20.75], P = 0.09). Adjusting for age and initial total symptom score, earlier therapy was protective against delayed symptom resolution (P = 0.01). Conclusion: This pilot study suggests that initiating VRT within the first 30 days after SRC is associated with earlier RTP and symptom resolution. Further prospective trials to evaluate if even earlier VRT should be pursued to further improve recovery time. Clinical Relevance: Clinicians should screen for vestibular dysfunction and consider modifying follow-up schedules after SRC to initiate VRT within a month of injury for improved outcomes.

Sport-related injuries (SRI) can be foreseen and averted when mechanisms and risk factors are completely understood. An appreciation of the relationship between sport-related concussion (SRC) and lower extremity musculoskeletal injuries (LEMI) is emerging amid professional and collegiate athletes. However, findings of such a relationship in adults may not be generalizable to younger populations, and the literature has not addressed this relationship in adolescents. The purpose of this cross-sectional quantitative study was to examine the relationship between SRC and LEMI in high school athletes. The dynamic model of etiology in sport injury provided the study's conceptual framework. A de-identified secondary dataset of high school athletic injuries was obtained from the Athletic Training Practice Based Rehab Network and analyzed with descriptive and inferential statistics. Concussions, knee sprains, and ankle sprains represented about 12%, 17%, and 70%, respectively, of the 1,613 cases in the dataset. Chi-square tests revealed that SRCs, and the number of SRCs, were associated with knee sprains [(p < .001), Cramer's V = .148] and ankle sprains [(p < .001), Cramer's V = .545]. This study may promote positive social change by prompting further retrospective and prospective studies to clarify whether a relationship exists between SRC and LEMI in high school athletes, and if so, whether this relationship is causal in nature. New knowledge may be used to guide practices and policies to reduce sports injuries in high school athletes, which may lead to fewer SRIs among adolescents, fewer school absences, more physical activity, and better health and well-being throughout the lifespan, thereby promoting a more active, productive, and healthy society.

Yes / Sport-related concussion (SRC) and physical pain are both associated with poor mental health, impaired cognition, and reduced quality of life. Despite SRC and physical pain often co-occurring, there is little research that investigates these two factors together, and therefore it is difficult to conclude which of these contributes to the negative outcomes asso ciated with them. Therefore, the present study aimed to investigate the effect of SRC and physical pain on mental health, cognitive ability, and quality of life. Depression was measured using the Center for Epidemiological Studies Depression Scale, anxiety was assessed using the State-Trait Anxiety Inventory while the SF-12 recorded health-related quality of life. A trail making task (TMT) assessed cognitive flexibility of participants. Analysis of 83 participants (43 concussed) revealed that SRC led to reduced accuracy on TMT(A) and (B), whereas physical pain was responsible for poorer mental health and reduced quality of life. This study highlights the influence that SRC has on cognitive ability and the impact that physical pain has on mental health and quality of life. With this information, we are better placed to predict the negative consequences of SRC and physical pain and therefore tailor support accordingly.

Introduktion: Handboll är en populär lagsport som innehåller kroppskontakt, hopp och sprints. Det är dock även en skadedrabbad sport, där bla huvudskador är vanligt. Huvudskador, eller sport related concussion (SRC), är en allvarlig skada som kan leda till komplikationer senare i livet. Tidigare forskning, gällande risken av att drabbas av SRC, har visat skillnader mellan kön samt positioner. Inom svensk handboll är de flesta SRC studier utförda på högsta eliten. Syftet med denna studie var därför att kartlägga förekomsten av SRC, eventuella skillnader mellan positioner, kön, samt symtom och metod för återgång till träning bland division 1 spelare och NIU/RIG-elever. Metod: En online enkät med 22 frågor uppdelat i tre delar skapades. Frågorna validerades genom face-validity samt en pilotstudie. Enkäten skickades sedan ut till alla division 1 klubbar och NIU/RIG-gymnasier, där tränarna/lärarna själva fick distribuera enkäten till sina elever/spelare. Resultat: Förekomsten av SRC av de som svarade i division 1 och NIU/RIG var 34,9%. Resultatet visade att gruppen målvakter rapporterade flest SRC av alla positioner. Kvinnliga spelare rapporterade signifikant fler antal SRC jämfört med herrspelare (58 vs 30, p=0,018) samt även fler olika symtom efter skada jämfört med herrspelarna. Vanligaste strategin för återgång till idrott oavsett kön och position var hjärntrappan. Konklusion: Sammanfattningsvis visade vår data att förekomsten av SRC bland handbollsspelare på div 1 och NIU/RIG är något lägre än tidigare studier på elitspelare. Resultatet att damspelarna rapporterade fler antal SRC, samt fler och mer varierade symtom än herrspelarna stämmer överens med flera tidigare studier. Den vanligaste vägen tillbaka till handbollen var via hjärntrappan. Vår undersökning bidrar till att öka kunskapen om SRC:s inom handbollen och förhoppningsvis kan den bidra till att förebygga denna typ av skada i framtiden. / Introduction: Handball is a popular sport that contains a lot of body contact, jumps and sprints. It is also an injury-prone sport, where head injuries are common. Head injuries, or sport related concussion (SRC), is a serious injury that may cause complications later in life. Previous research on the risk of SRC have shown differences between gender and within player position. In Swedish handball, available studies on SRC:s include mostly the highest elite. Thus, we aimed to study the prevalence of SRC, differences between positions, gender, symptoms and method of return to training among Division 1 players and NIU/RIG-students. Method: An online survey with 22 questions divided into three parts was created. The questions were validated through face validity and a pilot study. The survey was then distributed to all division 1 clubs and NIU/RIG high schools, where coaches/teachers were responsible for distributing the survey to their students. Results: The SRC prevalence among the Division 1 and NIU/RIG-student respondents, was 34.9%. Goalkeepers reported the highest incidence of SRC of all positions. Female players reported a significantly higher number of SRC compared to males (58 vs. 30, p=0.018). Furthermore, females reported a more diverse range of post-injury symptoms. The most frequently used return-to-play strategy was the brain-ladder, regardless of gender or position. Conclusion: Our data revealed that the prevalence of SRC among division 1 and NIU/RIG handball players is slightly lower than previous studies on elite handball players. The result that female players reported a higher number of SRC and more varied symptoms than male players, aligns with several previous studies. The most common pathway back to handball was through the brain-ladder protocol. Our study contributes to increasing knowledge about SRC in handball and hopefully can help prevent this type of injury in the future.

Sammanfattning Bakgrund: Studier tyder på bristande kunskaper angående hanteringen av idrottsrelaterad hjärnskakning samt i rehabilitering efteråt. Ryttares återgång till fysisk aktivitet kopplat med en jargong som främjar en för snabb återgång, där saknas studier.  Syfte: Att undersöka och beskriva en grupp tävlingsryttares upplevelser och erfarenheter av att ha fått en idrottsrelaterad hjärnskakning samt återgången till sin idrott, vardagsliv samt fysisk aktivitet. Metod: Data från fem informanter insamlades via semistrukturerade intervjuer och har analyserats med en innehållsanalys. Resultat: I studien framgick det två teman; “Hur IH yttrade sig och påverkade vardagen” samt “Vägen tillbaka” med totalt tio kategorier samt 16 subkategorier. Utifrån resultatet framgick det brister i adekvat information vid vårdtillfället rörande återgång till fysisk aktivitet efter idrottsrelaterad hjärnskakning. Omgivningens reaktioner påverkade ryttarna initialt till en något långsammare återgång till fysisk aktivitet, samtidigt som de egna kraven på skötsel av hästen fanns ständigt närvarande. Konklusion: Studien tyder på att återgången fortfarande går för snabbt men att omgivningens påverkan, i kombination med egen förståelse samt att den tidigare jargongen börjat avta har lett till en långsammare återgång. Dock finns kvarvarande brister angående information kring hur återgången bör ske efter en idrottsrelaterad hjärnskakning inom vården. / Abstract Background: Studies indicate a lack of knowledge regarding the handling of the acute state of sport related concussion and during the rehabilitation afterwards. Equestrians return to physical activity associated with a jargon that promotes an over-rapid return, where studies are lacking. Purpose: To investigate and describe a group of competing equestrians experiences of receiving a suspected or diagnosed sport related concussion and also their return to sport, everyday life and physical activity. Method: Data from five informants were collected through semi structured interviews and analysed with a content analysis. Results: The study showed two themes; “How SRC expressed and influenced everyday life” and “The way back” with a total of ten categories and 16 subcategories. Based on the result, there were shortcomings in adequate information from the time of health care treatment regarding the return to physical activity after a sport related concussion. The society's reaction initially affected the riders to a slower return to physical activity, while the own requirements for taking care of the horse were constantly present. Conclusion: The study indicates that their return still goes on too quick, but the surroundings effects, in combination with their own understanding and that the previous jargon has begun to decline has led to a slower return. However, there are remaining deficiencies regarding the information about how the return should take place after a sport related concussion within the healthcare system.