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2020 CASEM Poster Presentations

Clinical Journal of Sport Medicine: May 2020 - Volume 30 - Issue 3 - p e88-e110
doi: 10.1097/JSM.0000000000000844
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A Qualitative Assessment of Return to Sport: Does Gender Matter?

Allison M. Morgan, BA, Claire E. Fernandez, BS, Michael Terry, MD, and Vehniah Tjong, MD

Affiliation: Northwestern University Feinberg School of Medicine, Chicago, IL.

Objective: To explore differences in how elite female and male athletes perceive and approach injury and return to sport.

Study Design: Case series.

Subjects: Fifteen collegiate athletes (6 females and 9 males) from a single university who underwent orthopaedic surgery following is injury with at least 2 years follow-up.

Observation Technique: Semi-structured, open-ended interviews were conducted individually. Athletes were asked about factors influencing recovery, rehabilitation, and their return to or retirement from sport.

Outcome Measures: Codes, categories, and themes were derived within and across genders and recruitment ceased when thematic saturation was achieved.

Results: Three major themes emerged. First, there was a common athlete experience regardless of gender. Men and women described the centrality of the athlete role to their sense of self. Two gender specific themes were identified. Female athletes sought empathy and trust from their social supports and expressed frustrations in perceived lack of empathy. With greater perceived external supports, male athletes' greatest challenges came from their own psyche. Male athletes struggled with body image and experienced weight gain or loss as a source of self-consciousness and the greatest barrier to successful recovery.

Conclusions: Female and male athletes shared common motivating, enabling, and challenging factors in return to sport following injury and surgery. The most important findings of the present study were the differentiated challenges male versus female athletes experienced. Female athletes found difficulty with interpersonal relationships and external support, while male athletes struggled internally with their own body image and changing self-concept. Understanding gendered experiences in sport is critical to ensure all athletes are appropriately counseled and supported as they cope with injury and seek to return to sport.

Anteromedial Portal (AMP) Double Bundle (DB) Anterior Cruciate Ligament Reconstruction Yields Similar Outcomes to Non-AMP Femoral Drilling DB Techniques: A Systematic Review of Comparative Studies

Tushar Tejpal, BHSc (Cand.),* Arnav Gupta, MD (Cand.),† Ajaykumar Shanmugaraj, BHSc,‡ Nolan S. Horner, MD,‡ Nicole Simunovic, MSc,‡ Devin C. Peterson, MD,‡ and Olufemi R. Ayeni, MD, PhD‡,§

Affiliations: *Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; †Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; ‡Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; and §Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.

Objective: Biomechanical studies have shown double-bundle ACLR to have increased anterior and rotational stability compared to single-bundle (SB) ACLR. It is unclear if drilling technique [AMP, outside-in (OI) or transtibial (TT) drilling] is superior to others when using a DB graft. This study systematically assesses the outcomes and complications in patients undergoing DB ACLR through an AMP technique compared to other femoral drilling techniques.

Data Sources: PUBMED, MEDLINE and EMBASE were searched in April 2018. Non-randomized studies were assessed using the Methodological Index for Non-Randomized Studies (MINORS), whereas randomized studies were assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Main Results: Ten studies satisfied the inclusion criteria comprising of 722 patients. Three hundred fifty-one patients underwent DB ACLR using AMP drilling (mean age 32.7 ± 4.7 years), 318 patients had DB ACLR using OI drilling (mean age 31.9 ± 4.1 years) and 53 received a DB ACLR using TT drilling (mean age 26.5 ± 2.0 years). No significant (P < 0.05) difference in post-operative Tegner and Lysholm scores was found between AMP and OI groups post-operatively. AMP patients had a lower anterior and posterior graft bending angle (GBA) compared to OI patients. Four patients (1.1%) in the AMP group had graft re-ruptures compared to 9 re-ruptures (2.8%) in the OI group. There were no reports of re-rupture in the TT group.

Conclusion: DB AMP ACLR results in significantly improved functional outcome scores postoperatively. AMP techniques yield similar functional outcomes to OI ACLR. No direct comparison in functional outcomes scores are available between AMP and TT techniques. Low overall complications and revisions rates were observed for patients undergoing DB AMP ACLR and were found to be similar to those of other femoral drilling techniques. Due to a steeper GBA in patients undergoing OI or TT ACLR relative to AMP ACLR, patients treated with OI or TT femoral drilling may have increased strain placed on the graft. Due to various limitations in the currently available literature, it is not currently possible to make a definite conclusion of whether AMP is superior to non-AMP techniques in the setting of double bundle ACLR.

Predictors of Pain, Function and Health-Related Quality of Life Outcomes Following Arthroscopic Management of Femoroacetabular Impingement

Jeffrey Kay, MD,* Nicole Simunovic, MSc,† Diane Heels-Ansdell, MSc,‡ and Olufemi R. Ayeni, MD, PhD, FRCSC,†,‡ on behalf of the FIRST Investigators

Affiliations: *Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; †Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; and ‡Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.

Objective: The goal of the current study was, using data from the Femoroacetabular Impingement (FAI) Randomised controlled Trial (RCT) (FIRST), to identify patient factors associated with improved pain scores, functional hip scores, and health-related quality of life after arthroscopic management of FAI at 1-year post-operative.

Study Design: Prognostic study of the recently completed FIRST trial, a multi-centre, concealed RCT design.

Subjects: Adults aged 18 to 50 diagnosed with non-arthritic FAI.

Outcome Measures: A total of 13 prognostic factors (treatment group [lavage, lavage with labral repair, or osteochondroplasty], impingement subtype, age, sex, impingement severity, degree of osteoarthritis [as per Tonnis and Heinecke grading], presence of comorbidities, BMI, baseline scores, and adjudicated quality of surgery) were chosen a priori that would be expected to predict surgical outcomes at 12 months post-operative. A multivariable linear regression was used to assess the change in VAS scores from baseline to 12 months post-operative as the primary outcome, as well as HOS-ADL, HOS-Sport, iHOT-12, SF-12 PCS, SF-12 MCS, and EQ-5D as secondary outcomes. The tests were all 2-tailed with alpha = 0.05.

Results: A total of 154 patients had VAS scores at 1-year post-operative, with an R2 of 0.39 for the linear regression model. A lower BMI (Adjusted mean difference [AMD], 4.48 for a 5-unit decrease in BMI; 95% confidence interval [CI], 0.33-8.63; P = 0.035), and more pain at baseline (AMD; 0.78 for every 1-unit increase in baseline pain on the 100-unit VAS, 95% CI, 0.60-0.95; P < 0.001) were significantly associated with less pain at 1 year. There was a significant negative association between increasing age and 1-year EQ-5D scores (AMD, −0.04 for every 10 years increase in age; 95% CI, −0.07 to −0.006; P = 0.020). The degree of impingement, severity of osteoarthritis, type of procedure, and adjudicated quality of surgery were not significantly associated with improvement across all any outcomes at 1-year post-operative.

Conclusions: This study identified that lower BMI and age are predictive of improved pain and health utility scores following arthroscopic management of FAI at 1-year post-operative. These results may be a helpful adjunct in clinical decisions for this patient population.

The Burden of Sport-Related Concussion in High School Students: Lifetime Prevalence, 1-Year Incidence and Persistent Symptoms

Amanda M. Black, CAT(C), PhD,*,†,‡ Jocelyn McCallum, BHPE, CAT(C),*,†,‡ Paul H. Eliason, MSc,*,†,‡ Brent E. Hagel, PhD,*,†,§,¶,‖ and Carolyn A. Emery, PT, PhD*,†,‡,§,¶,‖

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

Objective: To examine the lifetime prevalence and 1-year incidence of sport- and recreational-related concussion and persistent symptoms following concussion among high school students (ages 14-19 years) in Alberta, Canada.

Study Design: Cross-sectional.

Subjects: High school students (n = 2029; 958 male, 1048 female, 23 identified as “other”) from 24 schools in Alberta, Canada.

Observation Technique: Students completed an anonymous online survey during class (October 2018–March 2019). Students identified their top 3 sport and/or recreational activities over the past year.

Outcome Measures: Self-reported lifetime prevalence and 1-year incidence of sport-related concussion were described by sex with 95% confidence intervals (CI) adjusted for cluster by school. Self-reported persistent problems with memory, headaches, or dizziness following a sport-related concussion at time of the survey are described as proportions.

Results: Most high school students (1763/2029, 86.69%) reported participating in a sport and/or recreational activity in the past year. Of the 1971 students (97.14%) answering the question about lifetime concussion history, 263/923 males (28.40%; 95% CI: 21.77-36.33), 227/1027 females (22.10%; 95% CI: 17.96-26.89), and 3/21 “other” students (14.29%; 95% CI: 2.22-55.05) reported at least one concussion in their lifetime. 131/923 males (14.19%; 95% CI: 10.28-19.27), 99/1027 females (9.64%; 95% CI: 7.49-12.33), and 1/21 “other” students (4.76%; 95% CI: 0.46-35.28) reported at least one concussion in the past year. Of the 263 males with a lifetime history of concussion, 41 (15.6%) reported persistent problems with memory, 88 (33.5%) reported headaches, and 53 (20.2%) reported dizziness (21 missing responses). Of the 227 females with a concussion history, 51 (22.5%) reported persistent problems with memory, 116 (51.1%) reported headaches, and 86 (37.9%) reported dizziness (11-12 missing responses).

Conclusions: One in 4 high school students report at least one sport- or recreational-related concussion in their lifetime, and 1 in 9 students reported at least one concussion in the past year. Greater than 15% of males and 20% of females report current suffering from persistent symptoms due to their sport-related concussion. This may indicate a need for further clinical follow-up or improved communication at the time that students are cleared to return to sport.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding from the National Football League Scientific Advisory Board, Canadian Institutes of Health Research, Alberta Innovates, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation. We would like to acknowledge the research coordinators, research assistants, school districts and all of teachers and students involved for their time and support in completing this project.

Using Inertial Sensor Technology in Capturing Differences Between Successful and Unsuccessful Balance Tasks in Youth Female and Male Soccer Players

A. M. Alanen, PT, MSc,*,‡ L. Benson, PhD,*,†,‡ M. Critchley, MSc,*,‡,§ C. van den Berg, MSc,*,‡ R. Ferber, PhD, ATC,*,† and K. Pasanen, PT, PhD*,‡,§,¶

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology University of Calgary, Calgary, AB, Canada; †Running injury clinic, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada, of Kinesiology, University of Calgary, Calgary; ‡Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; §McCaig Institute for Bone and Joint Health, University of Calgary, Calgary; ¶Tampere Research Center of Sport Medicine, UKK Institute, Tampere, Finland.

Objective: To compare successful and unsuccessful balance tasks by analyzing the differences in inertial measurement unit (IMU) data.

Study Design: Cross-Sectional study.

Subjects: Seventy-one youth soccer players (37 males and 34 females) were recruited from the U16/17 teams of a soccer club in the Calgary area.

Observation Technique: Players performed a single leg static balance test (SLSBT) on a balance pad (Airex Balance Pad Elite, 48 cm × 40 cm × 6 cm, Alcan Airex, Sins, Switzerland) and a single leg drop down test (SLDDT) from 30 cm height on balance pad. Balance was assessed by marking “successful” or “unsuccessful” depending on if the participant was able to stand 20 seconds without losing balance (SLSBT, n = 13) and 5 seconds after landing (SLDDT, n = 19). Players wore 3 IMU sensors (Shimmer3 IMU; lower back, left and right shin). All balance trials were videotaped. Videos were tagged on Dartfish (Dartfish Live S) and synced with data collected on the IMUs. Data were analyzed using Stata (StataCorp LP) and Matlab (MathWorks). The measures for successful trials were compared with unsuccessful trials using Wilcoxon signed-rank test. Confidence intervals were calculated for medians.

Outcome Measures: The outcome measures were the peak and SD of the resultant acceleration for all IMUs.

Results: The median peak resultant acceleration and SD was greater for unsuccessful trials than successful trials. Significant differences were found between SD medians for SLSBT and SLDDT (unsuccessful vs successful) with lower back sensor; SD median (SLSBT) was 0.20 m/s2 (95% CI 0.15-0.24) versus 0.12 m/s 2 (95% CI 0.09-0.15), SD median (SLDDT) was 1.51 m/s2 (95% CI 1.21-1.81) versus 1.05 m/s2 (95% CI 0.8-1.29). These results were statistically significant (P < 0.05).

Conclusions: The SD of the resultant acceleration measured with IMU is significantly different between successful and unsuccessful balance trials. These results show that using accelerometer data in movement analysis can provide coaches valuable information when planning effective training programs.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. The authors would like to thank the players and coaches for participation and cooperation.

Perceptions of Injury, Risk and Prevention in Youth High School Rugby: Are Coaches Ready for a Neuromuscular Training Injury Prevention Strategy?

Isla Shill, BSc,*,† Amanda M. Black, CAT(C), PhD,*,†,‡ Craig Barden, PhD (candidate),§ Carly McKay, PhD,§ Kati Pasanen, PT, PhD,*,†,¶,†† Brent Hagel, PhD,*,†,‡,‖,** and Carolyn A. Emery, PT, PhD*,†,‡,‖,**

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

Objective: To describe coaches' perceptions of injury, risk and neuromuscular training (NMT) warm-up injury prevention strategies in high school rugby.

Study Design: Cross-sectional study.

Subjects: Eighteen coaches (8 female, 10 male) from the Calgary Senior High School Athletics Association 2019 Rugby League.

Observation Technique: Coaches completed the online SHRed (Surveillance in High Schools to Reduce Injuries and their Consequences) post-season High School Rugby Coach Survey.

Outcome Measures: Coaches' perceptions of injury, risk and prevention were measured using a Likert scale (1 = Strongly disagree, 2 = Disagree, 3 = Slightly disagree, 4 = Neither, 5 = Slightly agree, 6 = Agree, 7 = Strongly agree).

Results: Five of 18 (28%) coaches had heard of NMT warm-ups; only 2 (11%) were using NMT warm-ups. However, 83% of coaches would like their team to complete a rugby-specific warm-up program prior to every game and training session. Coaches perceived that concussion (median, range; 7, 4-7) was the most severe injury whereas contusion (2, 1-4) was the least severe. Coaches felt neutral towards players being at a high risk of injury (5, 2-7) and the expectation that one of their players would sustain an injury next season (4, 1-6). Coaches strongly agreed that it is possible to prevent rugby injuries (7, 5-7), that exercises shown to prevent injuries should be performed by rugby players (7, 6-7) and should be incorporated into school rugby training (6, 1-7). Coaches strongly agreed that completing a rugby-specific warm-up program prior to every game and training session would reduce the risk of player injury (6, 5-7) and improve balance, agility, and strength (7, 5-7). Fifty-nine percent of coaches agreed/strongly agreed that balance exercises could prevent rugby injuries compared with a warm-up jog (50%) and cutting exercises (25%). Additionally, 28% of coaches agreed/strongly agreed that neck strengthening exercises could prevent concussion.

Conclusions: Coaches perceive concussion to be the most severe rugby injury. They held neutral perceptions towards injury risk in high school rugby, but are receptive to injury prevention strategies. Educating coaches on high school rugby injury risk and evaluating NMT warm-up strategies are needed to improve player safety.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge the funding from Canadian Institutes of Health Research, Alberta Innovates, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation. We would like to acknowledge the research coordinators, research assistants, school districts and all of teachers, coaches and students involved for their time and support in completing this project.

Feasibility, Reliability, and Concurrent Validity of a Field Test of Exertion in High School Students

Lauren N. Miutz, EP-C, MSc,*,† Amanda M. Black, CAT(C), PhD,*,†,‡ Matt J. Jordan, PhD,*,‖ Carolyn A. Emery, PT, PhD,*,†,‡ and Kathryn J. Schneider, PT, PhD*,†,‡,§,¶

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; §Acute Sport Concussion Clinic, Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; ¶Evidence Sport and Spinal Therapy, Calgary, AB, Canada; and ‖Canadian Sport Institute Calgary, Calgary, AB, Canada.

Objectives: (1) To evaluate the feasibility of a field-based aerobic capacity test (modified shuttle run test: mSRT), (2) to examine mSRT test-retest reliability, and (3) to evaluate the concurrent validity of the mSRT compared with the Buffalo Concussion Treadmill Test (BCTT) in uninjured high school students.

Study Design: Validation study, including test-retest reliability.

Subjects: Eighty high school students [male (n = 60), female (n = 20)] enrolled in sport performance/physical-education courses or student-athletes (age 15-17 years) in Calgary, AB, Canada.

Observational Technique: Participants completed the mSRT twice and BCTT once. All testing sessions took place one week apart in one of the 2 randomly selected orders: 1. mSRT1, 2. mSRT2, 3. BCTT or 1. BCTT, 2. mSRT1, 3. mSRT2. Heart rate (HR) utilizing a Polar HR monitor, self-reported rating of perceived exertion (RPE), and overall symptom levels were assessed throughout each session. 

Outcome Measures: Peak HR (HRpeak) was determined prior to termination of each test. Test termination was defined as voluntary exhaustion or symptom threshold (ie, an increase in symptoms >2 on the overall condition scale). Pre-and post-exertion testing RPE and overall condition (Likert scale 0-10/10) were also obtained throughout the tests. Intraclass correlation coefficients to assess HRpeak attained between mSRT1 and mSRT2 and between mSRT1 and BCTT. Bland-Altman 95% limit of agreement (LOA) was estimated to evaluate HRpeak agreement across tests.

Results: The mSRT was feasible, with 94% of participants (n = 75/80) completing all testing sessions with no adverse events reported. The mSRT had a moderate level of test-retest reliability for males (ICC = 0.68) and females (ICC = 0.62). Bland-Altman plots displayed mean differences between HRpeak on the mSRT1 and BCTT of −2.62 (95% CI −7.14 to 1.91) with LOA of −36.09 to 30.86 for males and −2.15 (95% CI −6.30 to 2.00) with LOA of −19.88 to 15.58 for females. Median HRpeak was highest following the BCTT in males (187 bpm) and the mSRT2 in females (192 bpm). Median RPEpeak (18 range: 7-20) and maximum stage achieved (23-males; 24-females) was highest following the BCTT. Self-reported fatigue or low energy was the most commonly reported symptom following exertional testing.

Conclusions: The mSRT was a feasible test of exertion with moderate reliability in high-school students without concussion. Further research is warranted into the application, reliability and concurrent validity in youth following concussion.

Acknowledgments: We acknowledge funding from Alberta Children's Hospital Foundation, Vi Riddell Pediatric Rehabilitation Research, and Integrated Concussion Research Program. Thank you to the teachers and students within the sports performance/physical education program for supporting this project. Thank you to Edge School for Athletes and the athletes and coaches within this school for supporting this project. We acknowledge and would like to thank all of the research coordinators: Cody van Rassel and Stacy Sick. The Sport Injury Prevention Research Centre is one of the International Research Centers for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee.

On-ice Sport Specific Skills and Rate of Injury in Youth Ice Hockey Players

Paul Eliason, MSc,*,†,‡ Luz Palacios-Derflingher, PhD,*,§ Brent E. Hagel, PhD,*,‡,§,¶,‖ Vineetha Warriyar K.V., PhD,* Willem Meeuwisse, MD, PhD,* and Carolyn A. Emery, PT, PhD*,†,‡,§,¶,‖

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

Objective: To evaluate the association between sport-specific skill performance and game-related injury rates in youth ice hockey players.

Study Design: Prospective cohort.

Subjects: Youth ice hockey players (aged 11-17) were recruited from youth ice hockey teams in Calgary, Alberta over 3 seasons of play (2013-2015).

Observation Technique: On-ice skill performance was based on the forward to backward transition agility with the puck (seconds), a key component of the Hockey Canada Skills Test (HCST) battery.

Outcome Measures: All youth ice hockey-related injuries were identified by a team safety designate as part of a validated injury surveillance methodology in youth ice hockey. Multilevel mixed-effects Poisson regression was performed to estimate the incidence rate ratio (IRR) associated with forward to backward transition agility (seconds) with adjustment for player position (forward, defensemen, goaltender), level of play (Pee Wee ages 11-12; Bantam ages 13-14; Midget ages 15-17), and body checking policy (allowing vs disallowing body checking), with a random effect at a team level.

Results: In total, 422 players (408 male, 14 female) players were recruited; 15 players participated in more than one season. There were 38 game-related injuries (including 16 concussions) that occurred during the playing season and after HCST was measured. To complete the forward to backward transition agility, uninjured players averaged 16.85 seconds (SD = 2.33), while injured players averaged 15.52 seconds (SD = 2.00). Using multilevel mixed-effects Poisson regression, forward to backward transition agility was not associated with the rate of injury (IRR = 0.98, 95% CI; 0.82-1.17).

Conclusions: We did not find an association between a measure of on-ice sport-specific performance, forward to backward transition agility, and game-related injury rates in youth ice hockey players. Future analyses will consider more players and additional components of on-ice performance. This research will inform skill development programs in youth ice hockey.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge the funding from Canadian Institutes of Health Research, Alberta Innovates Health Solutions, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation. We would like to acknowledge Hockey Canada and all team safety designates, coaches, players, and parents involved for their time and support in completing this research project.

Is Early Sport Specialization in Canadian Junior High School Students Associated With Injury Risk?

Carla van den Berg, MSc,* Chris Whatman, PT, PhD,† Luz Palacios-Derflingher, PhD,*,‡ and Carolyn Emery, PT, PhD*,†,‡,§,¶

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada; †Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand; ‡Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; §Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada; Health, University of Calgary, Calgary, AB, Canada; and ¶McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.

Objective: To evaluate the association between early sport specialization and previous musculoskeletal injury in Canadian junior high school students.

Study Design: Cross-sectional study.

Subjects: Two hundred thirty-eight grade 7 to 9 students (51.3% females) from 4 junior high schools in Calgary, Canada.

Observation Technique: Participants completed a questionnaire on demographics, sport participation, and injury history in the previous 12-months. Additionally, a research coordinator interviewed each student individually to ask 3 questions related to sport specialization; “Do you train for a sport more than 8 months of the year?” “Have you quit other sports to focus on a main sport?” and “Do you have a primary sport that you consider to be more important than other sports?” A “Yes” answer was scored as 1, and “No” was scored as 0. A score of 0 to 1 indicated low specialization, 2 indicated moderate specialization, and 3 indicated high specialization.

Outcome Measures: Musculoskeletal injury included any injury sustained in a sport or recreational activity over the previous 12-months that resulted in the inability to complete a session, time loss, or medical attention. A multivariable logistic regression analysis was conducted to assess the association between sport specialization category (low, moderate, high) and odds of sustaining a musculoskeletal injury over the previous 12-months, adjusting for total hours of sport participation, sex, and clustering by school.

Results: 47.5% of participants reported low, 34.5% reported moderate, and 18.0% reported high sport specialization. There was no significant difference in the odds of sustaining a previous musculoskeletal injury between participants reporting moderate (odds ratio [OR] = 1.94, 95% CI 0.86-4.35) or high specialization (OR = 2.21, 95% CI 0.43-11.37) compared to low specialization.

The odds musculoskeletal injury significantly increased with increased hours of sport participation (OR = 1.001, 95% CI 1.000-1.002).

Conclusions: To our knowledge this is the first study of its kind in Canadian youth. These results contrast several previous studies that have reported increased injuries in highly specialized youth sport participants. This may be due to the younger age group of participants in the current study compared to previously reported studies.

Acknowledgments: The University of Calgary Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge participation from students and teachers in the Calgary Catholic School District.

A Comparison Between a Standardized (GLA:DTM Canada) and an Individualized (JointEffort) Exercise Program on Functional Mobility, Quality of Life, and Pain Management in Knee Osteoarthritis (OA) Patients

Jesse Oswald, BSc, Kristen I. Barton, BSc, MSc, PhD, MD, Emma Smith, BSc, MSc, Darren Mazzei, BSc, PT, Ania Kania-Richmond, BSc, PhD, C. Ryan Martin, BSc, MD, Prism S. Schneider, BSc, MSc, PhD, MD, Deborah Marshall, BSc, PhD, David A. Hart, BA, PhD, and Jackie Whittaker, PT, PhD

Affiliation: University of Calgary, Calgary, AB, Canada.

Objective: To assess the association between participation in a standardized (GLA:D) or individualized (JointEffort) exercise program and self-reported symptoms, quality of life (QOL), self-efficacy, and function in persons with knee osteoarthritis (OA).

Study Design: Quasi-experimental intervention study.

Subjects: A convenience sample of 17 (median age 65 years [range 57-81], 57.1% female) GLA:D and 23 (median age 64 years [range 52-84; 62.5% female] JointEffort participants with a primary care physician or orthopaedic surgeon knee OA diagnosis.

Intervention: The GLA:D program consists of 2 education and 10 small group-based neuromuscular exercise training sessions over 6 weeks. The JointEffort program consists of an individualized program design, nutritional seminar (registered dietician), and small group-based exercise training twice weekly for 6 weeks.

Outcome Measures: Outcomes collected at baseline and program completion (2-months) included: demographics (weight, height, body mass index [BMI]); self-reported knee-related symptoms, function, and QOL (Knee Injury and Osteoarthritis Outcome Score [KOOS]); pain (Intermittent and Constant Osteoarthritis Pain Score [ICOAP]); health-related QOL (EuroQOL-5 Dimensions Score [EQ-5D-5L]); arthritis-related self-efficacy (ASES); and 30 seconds Chair Stand Test (CST) and 40 m Fast Paced Walk Test (FPWT) performance. Mean (95% CI) change in all outcomes from baseline to 2-months were calculated and mean between group difference (95% CI) used to compare study groups.

Results: 100% of participants completed the intervention and follow-up testing. Weight (−0.5 [−1.45 to 1.5]), height (1.7 [−0.03 to 0.1]), and BMI (−0.2 [−0.5 to 0.6]) were similar between groups. GLA:D participants demonstrated decreases in KOOS5 (−9.0 [−15.6 to −2.5]), ICOAP (−5.8 [−9.1 to −2.5]), and EQ-5D-5L (−1.2 [−2.1 to −0.2]), scores over the 2-month period. JointEffort participants demonstrated decreases in KOOS5 (−7.8 [−13.9 to −1.7]) and ICOAP (−2.9 [−5.4 to −0.3]) scores and increased ASES (4.8 [0.27 to 9.3]) score. Both intervention groups saw improvements in CST (GLA:D 3.5 [1.2 to 5.7]; JointEffort 2.3 [1.0 to 3.6]) and FPWT (GLA:D −2.6 [−3.3 to −1.9]; JointEffort −1.7 [−3.1 to −0.3]), performance. No between group differences were detected for any of the self-reported or physical function outcomes.

Conclusions: These findings provide preliminary evidence that the GLA:D and Joint Effort exercise programs result in similar improvements in self-reported symptoms, function, pain, QOL, and functional performance in persons with knee OA.

Does Peer to Peer Learning Facilitated by an iPad Application Help Coaches Learn a Neuromuscular Training Warm-up Prevention Program?

Larissa M. Taddei, BKin,*,† Larry Katz, PhD,† Carla van den Berg, MSc,*,† Anu M. Räisänen, PT, PhD,*,† S. Nicole Culos-Reed, PhD,† Carolyn Emery, PT, PhD,*,†,‡,§,¶,‖ and Kati Pasanen, PT, PhD*,†,‡,‖,**

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

Objective: To evaluate the impact of a standard workshop versus a technology-integrated instructional workshop on coaches' confidence and ability to recognize mistakes in neuromuscular training (NMT) warm-up exercises.

Study Design: Cluster randomized controlled trial.

Subjects: Calgary Minor Soccer Association coaches.

Intervention: Coaches within each club randomly attended one of 2 workshops offered to their club to learn a NMT warm-up: the control workshop (standard instruction), or intervention workshop (technology-integrated instruction).

Outcome Measures: The soccer NMT warm-up exercise test is a 16-question multiple choice test (16 video clips of NMT exercises) in which the coaches identified common NMT exercise errors. The NMT warm-up exercise test was completed at the end of the workshop. Multivariable linear regression analysis was performed to explore the association between test results, controlling for other potential covariates, including self-efficacy in their ability to recognize NMT warm-up exercise errors (measured pre and post-intervention).

Results: Eighty-six youth soccer coaches from 6 Calgary Minor Soccer Association clubs attended a standard delivery workshop [n = 41 (76% male; 14% female), median age: 44, range: 28-53] or the technology integrated workshop [n = 45 (60% male; 40% female), median age 44, range: 18-49]. Mean NMT warm-up exercise test scores were 11.40/16 (95% CI; 10.78-12.02) in the control and 11.59 (95% CI; 10.95-12.23) in the intervention workshops. Variables considered for modeling in linear regression were sex (male/female), age (years), personal training experience (yes/no), previous use of injury prevention programs (yes/no), a volunteer coach (yes/no), number of years coaching soccer (years) and difference between beginning and end of workshop self-efficacy scale mean scores Workshop delivery method (β = −3.42, 95% CI: −8.814 to 1.98) and other variables were not associated with test score (R2 = 0.14). There was a statistically significant difference in self-efficacy scores between workshop delivery methods (P = 0.0061).

Conclusions: The workshop delivery method is not associated with coach test scores on the soccer NMT exercise test but there is an increase in self-efficacy scores for coaches in the intervention workshop. This is the first study to evaluate coaches' ability to apply their newly learned exercise knowledge based on workshop delivery methods.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the IOC. We acknowledge funding from the University of Calgary, Faculty of Kinesiology and the Sport Technology Research Lab for providing the Tablet Application.

Youth Basketball Coaches' Knowledge, Attitudes and Perceptions on Warm-up Practices and Injury Prevention

Anu M. Räisänen, PT, PhD,* Oluwatoyosi B. A. Owoeye, PT, PhD,*,† Kimberley Befus, MSc,* Carla van den Berg, MSc,* Kati Pasanen, PT, PhD,*,‡,§,¶ and Carolyn A. Emery, PT, PhD*,‡,§,‖

Affiliations: *Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada; †Department of Physical Therapy and Athletic Training, Doisy College of Health Sciences, Saint Louis University, Saint Louis, Missouri; ‡Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; §McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada; ¶Tampere Research Center of Sports Medicine, Tampere, Finland; and ‖Department of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: To determine if youth basketball coaches knowledge, attitudes, beliefs and sources of information regarding warm-up practices and injury prevention reflect evidence-informed neuromuscular training programs aimed to prevent sport-related injuries in youth.

Study Design: Cross-sectional survey study.

Subjects: Fifty high school or club youth basketball coaches.

Observation Technique: Prior to participating in an injury prevention workshop, coaches were invited to participate in a pre-season questionnaire regarding warm-up length, use of aerobic/agility/balance/strength/other components in their warm-up, injury-related knowledge, attitudes and beliefs and sources of information.

Results: Forty-eight percent of coaches (95% CI: 34.2-61.8) spent 10 minutes or less on a warm-up during team practices, followed by 42% (95% CI: 28.3-55.7) spending ≤15 minutes, 8% (95% CI: 0-15.5) spending ≤20 minutes and 2% (95% CI: 0-5.9) spending more than 20 minutes on the warm-up. All coaches included an aerobic component in their warm-up and other neuromuscular training components were included by 80.0% (95% CI: 68.3-91.7) of coaches for agility, 70.7% (95% CI: 56.8-84.3) for strength and 26.8% (95% CI: 13.2-40.4) for balance. Nine (18%) coaches included all 4 components in their warm-ups. Fourteen (28%) coaches included additional components in their warm-up, such as stretching and sport-specific drills. All coaches considered injury prevention to be important (agree 15%, strongly agree 85%) and agreed that it will be a priority in the upcoming season (slightly agree 13%, agree 33%, strongly agree 54%). Most coaches agreed to some extent that basketball injuries are preventable (slightly agree 31%, agree 52%, strongly agree 10%) and that participating in neuromuscular training would reduce player's risk of injury (agree 62%, strongly agree 30%). Fellow coaches were identified as the most common source for obtaining information about warm-up programs and injury prevention knowledge.

Conclusions: Only some components of effective neuromuscular training programs are included in warm-ups in youth basketball. Considering the level of evidence informing exercises such as balance training, it is important to create knowledge translation strategies that improve the adoption of neuromuscular training program in youth basketball. As other coaches are an important source of information, engaging coaches in knowledge translation activities should be explored.

Acknowledgments: The authors would like to thank all the coaches for their participation. This study is part of the Tendinopathies in Youth Basketball research project funded by the National Basketball Association and General Electric Healthcare (NBA/GE). The Sport Injury Prevention Research Centre is an International Olympic Committee Centre for the prevention of injuries in sport and protection of athlete health.

Neuromuscular Training Warm Up Improves Jump Performance and Reduces Knee Extension and Adduction Moments During Jumping in Female Adolescent Dancers

Karen Sudds, MSc,*,† Philipp Maurus, MSc,† Nico Kolokythas, MSc,* Sandro Nigg,† and Matthew A. Wyon, PhD*

Affiliations: *Institute of Sport, University of Wolverhampton, Walsall, United Kingdom; and †University of Calgary Sport Medicine Center, Calgary, AB, Canada.

Objective: To determine the effects of an 8-week neuromuscular training intervention (NMT) on jump performance and knee moments during counter-movement jumps (CMJ) in female adolescent dancers.

Study Design: Two-centre controlled trial.

Subjects: Twenty female subjects.

Intervention: One dance school was assigned to the intervention group (IG). A second dance school was assigned to the control group (CG). The IG performed the NMT program 3×-week for 8-weeks during the first 30-minute of their regularly scheduled dance classes. The CG continued with their regular dance classes routine.

Outcome Measures: Main measures were jump height (JH), knee extension (KEM), knee adduction moments (KADM), and hip extension moments (HEM) during the CMJ. Measured values of baseline were subtracted from the outcomes measured after the intervention (Post—Pre) to obtain a measure of change for the IG and CG. Change in outcome variables was compared between the IG and CG using independent t-tests. Finally, each change in outcome measures was compared against a mean of zero using one-sample t-tests. The alpha-level threshold was set at α = 0.05.

Results: The IG did not increase their JH compared to the CG. However, both groups increased JH (P < 0.01). The IG significantly decreased KEM compared to the CG (P < 0.01). The IG decreased KADM of the left leg during the CMJ compared to the CG (P < 0.01), and significantly decreased KADM in the right and left leg during the CMJ compared to zero (P < 0.05), while the CG did not change. Finally, the IG increased the HEM compared to the CG (P < 0.05).

Conclusions: The NMT significantly changed jump performance in both groups. However, the intervention changed the jumping strategy of the IG by significantly reducing moments at the knee and increasing moments at the hip. Further research is warranted to determine whether this intervention could be a mechanism to reduce knee injuries in dancers.

Is Neuromuscular Training Effective in Reducing Specific Lower Extremity Injuries in Youth Basketball?

Oluwatoyosi B. A. Owoeye, PT, PhD,*,† Kimberley Befus, MSc,† Anu Raisenen, PT, PhD,† Luz Palacios-Derflingher, PhD,†,‡ Carolyn A. Emery, PT, PhD,†,‡,§,¶,‖,** and Kati Pasanen, PT, PhD†,§,††

Affiliations: *Department of Physical Therapy and Athletic Training, Doisy College of Health Sciences, Saint Louis University, Saint Louis, Missouri; †Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; ‡Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; §Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; ¶Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; ‖McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada; **O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; and ††Tampere Research Center of Sports Medicine, UKK Institute, Tampere, Finland.

Objective: To evaluate the effectiveness of a NMT warm-up program in reducing the risk of all-complaint knee and ankle injuries, including patellar and Achilles tendinopathy in youth basketball.

Design: A 2-season quasi-experimental design comparing injury rates in players exposed (season 2) and unexposed (season 1) to an NMT warm-up intervention.

Participants: Ninety-four youth basketball teams, comprising 825 male and female players (age range: 11-18 years; season 1, n = 518; season 2, n = 307) in Alberta, Canada.

Intervention: A coach-delivered 10-minute SHRed Basketball Injuries NMT warm-up program, administered in season 2, including 13 exercises across aerobic, agility, strength and balance components. In the control season 1, teams completed their standard of practice warm-up.

Outcome Measures: All-complaint knee and ankle injuries, including patellar and Achilles tendinopathy were recorded weekly throughout 2 basketball seasons using a combination of validated injury surveillance methodology including team designate completed injury report forms and self-report modified Oslo Sport Trauma Research Centre Questionnaire. Poisson regression (with offset using exposure hours and adjusted for team cluster, sex, 2-season participation) was used to estimate incidence rate ratios (IRRs; 98.8% CIs, Bonferroni adjustment) for all-complaint injuries between seasons (preliminary analyses with statistical imputation of missing covariables). Logistic regression (adjusted for team cluster, sex, exposure hours, 2-season participation), was used to estimate odds ratios (ORs; 98.8% CIs) for players reporting at least one tendinopathy.

Results: The NMT warm-up program was protective for knee [IRR = 0.51 (98.8% CI: 0.35-0.75)] and ankle injuries [IRR = 0.68 (98.8% CI: 0.52-0.91)] but not for patellar [OR = 0.88 (98.8% CI: 0.44-1.73)] and Achilles tendinopathy [OR = 0.63 (98.8% CI: 0.18-2.18)].

Conclusions: The SHRed NMT warm-up program was effective in reducing all-complaint knee and ankle injury rates but ineffective for mitigating patellar and Achilles tendinopathy risk in youth basketball players. The aetiology of overuse injuries such as patellar and Achilles tendinopathy may be associated with basketball-related load. Further research is needed to examine the dynamics of basketball load and load management strategies as a potential target for prevention of tendinopathies.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding support from the National Basketball Association and General Electric.

Anabolic Steroids, Exercise, and Concussions in the Developing Brain: A Preclinical Study

Jason B. Tabor, MSc,* David K. Wright, PhD,‡,§ Jennaya B. Christensen, MSc,†,‡ Akram Zamani, PhD,‡ Reid Collins, MBT,† Sandy R. Shultz, PhD,‡ and Richelle M. Mychasiuk, PhD†,‡

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Department of Psychology, University of Calgary, Calgary, AB, Canada; ‡Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia; and §The Florey Institute of Neuroscience and Mental Health, Parkville, Australia.

Objective: Repetitive mild traumatic brain injury (RmTBI) is increasingly common in adolescents with >60% being sport-related concussions (SRC). Anabolic-androgenic steroid (AAS) consumption among younger elite athletes is a significant risk factor for impaired neurodevelopment. Given the overlapping symptomology of SRC and AAS use, we sought to investigate the behavioural and neuropathological outcomes associated with the AAS Metandienone (Met) and RmTBI on adolescent rats. Additionally, as exercise is intrinsic to athletes and may influence outcomes, rats were assigned to exercise or no exercise conditions.

Study Design: Preclinical randomized controlled trial.

Subjects: Sixty-two male, adolescent Sprague Dawley rats.

Intervention: Subjects were randomly assigned to treatment groups: (1) Steroid + Exercise; (2) Placebo + Exercise; (3) Steroid + No Exercise; and (4) Placebo + No Exercise. Rats in each of these groups were then randomly assigned to receive 3 mTBIs or sham injuries.

Outcome Measures: Following the injuries, a behavioural test battery was performed to assess for cumulative effects of Met and RmTBI on post-concussive symptomology. Post-mortem magnetic resonance imaging (volumetric, T2*, and diffusion weighted analyses), was conducted to examine markers of brain integrity and qRT-PCR assessed telomere lengths and mRNA expression of markers for neurodevelopment, neuroinflammation, stress responses, and repair processes.

Results: Although AAS and RmTBI did not produce cumulative deficits, AAS use was associated with detrimental outcomes including: changes to post-concussive cognition and behaviour; prefrontal cortex (PFC) atrophy and amygdala (AMYG) enlargement; damaged white matter integrity in the corpus callosum; and altered mRNA expression in the PFC and AMYG.

Conclusions: Findings corroborate previous results indicating that multiple SRCs negatively impacts neurodevelopment. Our pre-clinical results provide valuable insight into the effects of AAS exposure on adolescent brain development and can begin to inform decision making on AAS use for young elite athletes. While this study only included males, future research should include females as they have a lower, yet still significant prevalence of AAS usage.

Acknowledgments: The authors would like to thank the Alberta Children's Hospital Research Institute, Canadian Institute of Health Research, National Scientific and Engineering Research Council, and National Health and Medical Research Council for their financial contributions.

Co-designing a Toolkit to Help Sport Organizations and Key Stakeholders Implement the Canadian Guidelines on Concussion in Sport

Amanda M. Black, CAT(C), PhD,*,†,‡ Heather A. Shepherd, OT, MSc,*,†,‡ Stephanie Cowle, BAH,§ Pamela Fuselli, MSc,§ and Kathryn J. Schneider, PT, PhD*,†,‡,¶,‖

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; §Parachute, Toronto, ON, Canada; ¶Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; and ‖Evidence Sport and Spinal Therapy, Calgary, AB, Canada.

Objective: To design and evaluate a toolkit to help with implementation of the Canadian Guidelines on Concussion in Sport based on the barriers, facilitators, and implementation factors identified by key stakeholders.

Study Design: A sequential explanatory mixed method approach including a cross-sectional survey, semi-structured interviews, and 2 co-design workshops with key stakeholders.

Subjects: Sport stakeholders (coaches, administrators, athletes, parents, officials, healthcare professionals) with a range of experience and understanding of the guidelines.

Observation Technique: First, 225 individuals completed a survey guided by the theoretical domains framework that examined barriers and facilitators to concussion management as defined by the guidelines. Next, 14 participants further described barriers and facilitators during a semi-structured interview. Finally, the research team and community partners developed and presented potential toolkit components at 2 workshops. Additional feedback regarding toolkit components was collected from attendees and used to inform the resulting toolkit.

Outcome Measures: Key barriers to implementation and stakeholder recommended toolkit components and feedback.

Results: Toolkit components discussed at the workshop aimed to address 8 of the identified challenges to implementation of concussion protocols. First, educational resources that addressed the use of the Concussion Recognition Tool 5 and sport-specific case scenarios to help stakeholders practice using the tool was recommended. Key educational gaps to be addressed in the toolkit was more information regarding (1) initial management; (2) persistent symptom management that is specific to stakeholders; and (3) a guide to assist with finding appropriate concussion clinics within specific geographical areas. Forms and documentation to assist with communication between athletes, coaches, and healthcare professionals were also discussed. A roles and responsibilities matrix was developed to address confusion around roles and responsibilities across levels of sport.

Conclusions: The Canadian Guidelines on Concussion in Sport has been adopted by many organisations; however, full implementation of some components remains challenging. The findings of this project shows promise in filling the gap described by stakeholders.

Acknowledgments: We acknowledge funding from Parachute, through a project with the Public Health Agency of Canada (PHAC). The Sport Injury Prevention Research Centre is one of the International Research Centers for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. Thank you to Parachute, Jacqueline Tittley, Agnes Makowski, Suzanne Leclerc, Kerry MacDonald, Matt Jordan, Own the Podium and their partners COPSIN and COPSI, and the Coaching Association of Canada for their support and collaboration in this project.

Optimal Management of Low Back Pain in Sport: A Systematic Review

Jane S. Thornton, MD, PhD,* J. P. Caneiro, PhD,† Clare Ardern, PT, PhD,‡ Kellie Wilkie, PT,§ Larissa Trease, MD,¶ Anders Vinther, PT, PhD,‖ Kathryn Ackerman, MD, MPH,** Kathryn Dane,†† Sarah Jane McDonnell,‡‡ David Mockler,†† and Fiona Wilson, PT, PhD††

Affiliations: *Fowler Kennedy Sport Medicine Clinic, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; †School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia; ‡Division of Physiotherapy, Karolinska Institutet, Solna, Sweden; §Tasmania Institute of Sport, Hobart, Tasmania, Australia; ¶Orthopedics ACT, Canberra, Australia; ‖Department of Rehabilitation, Herlev and Gentofte Hospital, Copenhagen, Denmark; **Sports Medicine Division, Boston Children's Hospital, Boston, Massachusetts; ††School of Medicine Trinity College Dublin, Ireland; and ‡‡Sport Ireland Institute, Dublin, Ireland.

Objective: Low back pain (LBP) is a serious problem in sport which can negatively impact performance, result in protracted training and competition time loss and ultimately contribute to early athlete retirement. The aim of this systematic review was to determine the optimal management strategy (eg, conservative, medical or surgical) for LBP in athletes.

Data Sources: Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from earliest possible entry to June 2019 for randomized and quasi randomized trials, observational and cross-sectional studies with case control in adult athletes with LBP. Two reviewers conducted a title, abstract, and full-text review of eligible studies and their references. Inclusion and exclusion criteria were applied, data were extracted, and a quality assessment was completed. Primary outcomes of interest were pain, disability, and return to sport (RTS).

Main Results: Among 1483 references, 35 studies involving 1469 athletes were included in the review. Interventions to manage LBP included exercise (12 studies), activity or biomechanical modifications (6), manual therapy (6), corticosteroid injections (2), and surgery (9). There were 23 different outcome measures used across studies and no consensus on LBP definition, making it difficult to compare interventions. Pain and disability decreased across all interventions and RTS rates ranged from 74% to 100%. Exercise emerged as the highest value care for reducing pain and disability in athlete LBP, although there is insufficient evidence to recommend one exercise mode over another, and virtually no information regarding RTS. Surgery was associated with the highest and lowest RTS, and often followed a trial of conservative management. Studies were only of “fair” or “poor” quality and quality of synthesized evidence was low.

Conclusions: Due to high risk of bias, there is insufficient evidence to recommend manual therapy, corticosteroid injections, biomechanical and activity modifications alone for the management of LBP in sport. Surgery may be indicated when pain is refractory to conservative management and with careful patient selection. Exercise emerged as the top management strategy but rates of RTS are unknown. Well-designed prospective studies are sorely needed, which include clear definitions of LBP, control groups, and valid and consistent outcome measures for comparison.

Exercise Fidelity in Youth Basketball Players Performing the SHRED Injuries Basketball Neuromuscular Training Warm-up Program

Kimberley D. Befus, MSc,* Kati Pasanen, PT, PhD,*,†,‡,§ Amanda M. Black, CAT(C), PhD,*,†,¶ Sarah J. Kenny, PhD,*,†,‖ Meghan H. McDonough, PhD,*,‖ and Carolyn A. Emery, PT, PhD*,†,‡,¶,‖,**

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

Objective: To determine the extent to which youth basketball players adhered to the SHRED Injuries Basketball Neuromuscular Training Warm-up (SHRED NMT) program as measured by exercise fidelity.

Study Design: Prospective Cohort study.

Subjects: Sixty-six high school basketball players (46 females and 20 males) were video-recorded using 5 cameras from 3 angles while completing the SHRED NMT (aimed to reduce injury risk) as part of their normal practice routine.

Observation Technique: A single rater, trained in the delivery of the SHRED NMT and the use of the SHRED Injuries Basketball observation tool (SOT), observed the video clips and assessed exercise fidelity. Each player was observed completing the warm-up from start to finish using any of the 5 available camera views. The observer could re-watch any portion(s) of the video as many times as was necessary to assess fidelity.

Outcome Measures: The SOT is comprised of 4 to 6 required components consisting of technique (eg, upright posture) and volume (eg, 8 reps) for each of the 13 exercises. Each component was evaluated as to whether they were fully (correct on every repetition = 2 points), partially (correct on at least one repetition = 1 points) or not (never completed correctly = 0 points) completed. Exercise fidelity was calculated as the sum of scores for each component divided by the total score attempted by their team, as not all teams attempted all exercises or components.

Results: The overall mean fidelity score for all participants was 63% (95% CI, 60%-66%). The mean fidelity score for males was 57% (95% CI, 53%-62%) and 66% (95% CI, 62%-69%) for females. Forward run had the highest mean fidelity score for all participants at 89% (95% CI, 86%-92%) and 3D lunges had the lowest mean fidelity score at 43% (95% CI, 34%-52%).

Conclusions: To our knowledge, this is the first study to evaluate individual-level exercise fidelity based on their completion of the entire warm-up in youth basketball. Overall exercise fidelity scores were similar for male and female youth basketball players on a NMT warm-up. Future research should evaluate the effects of exercise fidelity levels on injury risk reduction.

Acknowledgments: This study is a sub-study of a larger cohort study which is funded by the National Basketball Association and General Electric Healthcare (NBA/GE). The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge the participation of basketball players and coaches supporting this study.

Delay in Diagnosis and Management of Adolescent Anterior Cruciate Ligament Injuries in a Publicly Funded Healthcare System

Lise A. Leveille, MD,*,† Tessa Ladner, BSc,† Pardeep Sidhu, BSc,‡ and Christopher Reilly, MD*,†

Affiliations: *British Columbia Children's Hospital, Vancouver, BC, Canada; †University of British Columbia, Vancouver, BC, Canada; and ‡The Royal College of Surgeons in Ireland—Medical University of Bahrain.

Objective: Identify patient factors contributing to delayed diagnosis and ACL reconstruction in adolescent patients.

Study Design: Retrospective Chart Review.

Subjects: Adolescent patients with history of ACL reconstruction.

Intervention/Observation Technique: Retrospective chart review.

Outcome Measures: Patient demographic data, history of physical therapy, household income (as determined by federal census data) and intraoperative status of the meniscus and articular cartilage. Time from injury to orthopedic referral, consult, and ACL reconstruction was calculated. A logistic regression model was constructed to determine the impact of household income, age, and sex on time to orthopaedic referral, consultation, and ACL reconstruction.

Results: Eighty-three patients were identified with a mean age of 14 years (range, 9-17). Twenty-eight patients were male (33.7%). Mean time from injury to orthopedic consult was 124 days. Mean time from injury to reconstruction was 286 days. Eleven patients (13%) had ligament reconstruction within 90 days of injury. Fifty-three patients (63.8%) had meniscal or articular cartilage damage at the time of ACL reconstruction. There was no significant effect of patient sex, age, or history of physical therapy on time to ACL reconstruction. Household income was found to have a significant effect on time to ACL reconstruction. For every $10,000.00 increase in household income, time to reconstruction was reduced by 19%. Using the median time to reconstruction of 223 days, this represents a decrease of 42 days. When time from injury to reconstruction was broken down, household income only had an effect on time from injury to referral with a decrease of 38.4% for every $10,000.00 incremental increase in household income. No association was found between time to ACL reconstruction and odds of meniscal or articular cartilage damage.

Conclusions: Increase in household income was associated with a significant decrease in time to orthopaedic referral. Further research is needed to determine specific factors contributing to delayed ACL diagnosis and specialist referral. In the current healthcare system, most adolescent patients are having their ACL reconstructed in a delayed fashion potentially contributing to an increased frequency of intra-articular pathology.

Arthroscopy Association of Canada Position Statement on Intra-articular Injections for Knee Osteoarthritis

Michaela Kopka, MD, FRCSC,* Brendan Sheehan, MD, FRCSC,† and Ryan Degen, MSc, MD, FRCSC,‡ Arthroscopy Association of Canada*,†,‡

Affiliations: *Banff Sport Medicine; †Dalhousie University; and ‡Fowler Kennedy Sport Medicine Clinic.

Objective: To provide up-to-date and evidence-based recommendations for the use of intra-articular injections in the treatment of knee osteoarthritis (OA).

Data Sources: The PubMed, Embase and Cochrane Library databases were searched for studies published between 2000 and 2018 investigating the use of intra-articular injections in the setting of knee OA. Intra-articular modalities reviewed included: corticosteroids (CS), hyaluronic acid (HA), platelet rich plasma (PRP), mesenchymal stem cells (MSc), and combination therapies. Three independent reviewers assessed the quality of each study. Studies comparing one intervention to another or to placebo, and assessing patient reported outcomes of pain and function were included. Those without a comparison group, inadequate follow-up, or un-reported outcome measures were excluded. Clinical recommendations were based on the results of the literature review as well as the expert opinion of experienced clinicians.

Main Results: The authors support a strong recommendation for the use of intra-articular CS as well as HA in patients with early knee OA in order to reduce pain and improve function in the short to medium term. Given significant heterogeneity in the literature, the authors cannot recommend for or against the use of PRP. There is insufficient evidence to make recommendations surrounding MSc. A fair recommendation is made for the use of CS-HA combination therapies, however, there is no evidence available to support the use of other combination treatments.

Conclusions: This review provides an evidence-based summary of intra-articular injections in the treatment of knee OA, as well as concise recommendations for clinical use within the Canadian healthcare landscape.

The Prevalence and Risk Associated With Injury in Competitive Trampoline and Tumbling Athletes Ages 8 to 25 years

Sheila Downie, BSc,* and Sarah J. Kenny, PhD*,†,‡

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary; Calgary, AB, Canada; †Alberta Children's Hospital Research Institute, University of Calgary; Calgary, AB, Canada; and ‡O'Brien Institute for Public Health, University of Calgary; Calgary, AB, Canada.

Objectives: To identify injury prevalence, severity and potential risk factors associated with injury in competitive Trampoline and Tumbling athletes ages 8 to 25.

Study Design: Cross Sectional.

Subjects: Competitive (provincial/national level) Trampoline and Tumbling (T&T) athletes ages 8 to 25 from 65 training facilities across Canada.

Observations: Following implied consent, volunteer participants completed an online survey comprised of age (years), sex, height (feet/inches or m/cm), weight (pounds or kg). Athletes identified their training club, training/competition exposure (years' experience, h/wk, mo/yr), co-current sport participation, event specialization and 1-year injury history [frequency, type, location, medical attention (yes/no), and time loss (d/wk/mo)]. Two definitions of injury were captured: time loss (ie, resulted in ≥1 day beyond day of onset) and medical attention (ie, resulted in participant seeking medical care).

Outcome Measures: Descriptive statistics (means, proportions, 95% confidence intervals) for athlete demographics, injury characteristics, and injury prevalence (proportion of athletes injured/total athletes responding to survey) are reported. Multivariable logistic regression will be utilized to examine associations between 1-year injury history and training/competition exposure variables. Proportions (95% confidence intervals) will be adjusted for cluster by province.

Results: Preliminary descriptive data from 30 athletes (median age 16.8 years old) illustrates that 60% (CI 95% 41-76; 11 female, 7 male) reported at least one time loss injury and 94% (CI 95% 82-98) sought medical attention for at least one injury in the previous year of training/competition. Time-loss injury rate is 60/100 athletes/yr and medical attention injury rate is 94/100 athletes/yr. Ankle [33% (95% CI, 14-58)] and head/face [22% (95% CI 7.9-48)] are the top 2 reported injury sites. Ligament sprains [22% (95% CI 14-58)] and concussion [17% (95% CI 6-35)] are the top 2 reported injury types. Associations between 1-year injury history and training/competition exposure will be estimated.

Conclusions: Injury rates among competitive Trampoline and Tumbling athletes are high. Based on preliminary data, nearly all athletes reported at least one medical attention injury, and a greater proportion of females reported injuries compared to males, with the most serious occurring in the lower extremity. It is recommended that further research focus on mitigation of lower extremity injury among these high-risk acrobatic young athletes.

Acknowledgments: We acknowledge funding from the Alberta Children's Hospital Foundation and Alberta Children's Hospital Research Institute. The Sport Injury Prevention Research Centre is one of the International Research Centers for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee.

Long-Term Effects of Multiple Concussions on Total Haemoglobin Reactivity Index in Active Retired Contact Sport Athletes

Jyotpal Singh, MSc,* Luke W. Sirant, BKin,* Steve Martin, MD,† Catherine A. Gaul, PhD,† Lynneth Stuart-Hill, PhD,† Gregory P. Kratzig, PhD,‡ Cameron Bowers, MSc,† Kathleen Leahy, BSc,† and J. Patrick Neary, PhD*

Affiliations: *University of Regina Faculty of Kinesiology and Health Studies, Regina, SK, Canada; †University of Victoria Faculty of Exercise Science, Physical and Health Education, Victoria, BC, Canada; and ‡Research and Strategic Partnerships, RCMP Depot Division/Ecole de la GRC, Regina, SK, Canada.

Objective: Explore the long-term effects of 3 or more prior concussions on total haemoglobin reactivity index to assess dynamic cerebral autoregulation (dCA) in physically active retired contact sport athletes.

Study Design: Cross-sectional study.

Subjects: Thirty-eight physically active male subjects participated. Nineteen (mean age = 63 ± 7 years) with a history of previous concussions (PC) were age matched to 19 (mean age = 64 ± 9 years) with no history of previous concussions (NPC). All participants had been contact sport athletes in their youth and/or adulthood.

Intervention: Subjects completed a 5-minute seated rest to establish physiological baseline, followed by a 1-minute standing washout period and 5-minutes of a 20 seconds squat-stand (0.05 Hz; 10 seconds down, 10 seconds up) protocol.

Outcome Measures: Near infrared spectroscopy (NIRS) was used to measure cerebral haemodynamics in both the right and left prefrontal cortices during all parts of the intervention protocol. NIRS measures included oxygenated (HbO2), deoxygenated (HHb), total (tHb) haemoglobin, and haemoglobin difference (HbDiff). Each NIRS variable was analysed using the change between the maximal and minimal values ([INCREMENT]MAX) during the 20 seconds squat-stand test. Finger photoplethysmography was used to monitor mean arterial pressure (MAP) to assess pressure alleviation (n = 18 per group) as the MAP difference from the first 6 seconds minus the last 4 seconds. [INCREMENT]MAX in total haemoglobin reactivity index (THx = tHb/MAP) was assessed over the 20 seconds squat-stand to reflect dCA. Independent Student t-tests were used to compare [INCREMENT]Max for each NIRS variable, blood pressure alleviation, and THx between the PC versus NPC (P ≤ 0.05).

Results: No significant differences or trends were observed in [INCREMENT]MAX in any of the NIRS variables or in THx. There were no significant differences in blood pressure alleviation (P > 0.05).

Conclusion: These results suggest that a history of 3 or more concussions did not reveal a significant impairment in the autoregulatory control over haemodynamic reactivity in those with PC versus NPC. Specifically, THx and blood pressure alleviation were not statistically different between groups. No differences in the NIRS variables indicate that prefrontal cortex oxygenation was similar between groups suggesting that the cellular metabolism was conserved in those with PC.

Acknowledgments: CASEM for funding this research.

Measurement Properties of the Adult Version of the Sport Concussion Assessment Tool 5th Edition Symptom Evaluation Using Rasch Analysis

Michael Robinson, PhD, CAT(C), ATC, Lisa Fischer, MD, Andrew Johnson, PhD, David Walton, PhD, PT, and Joy MacDermid, PhD, PT

Affiliation: Western University, London, Ontario.

Objective: The objective of the study was to evaluate the psychometric and measurement properties of the fifth edition of the Sport Concussion Assessment Tool (SCAT5) Symptom Evaluation using Rasch analysis.

Study Design: Cross sectional study using Rasch analysis.

Subjects: A total of 284 participants who were still experiencing concussion symptoms were included (130 males, 154 females, mean age 20.8 ± 10.4), with a total of 810 responses for the SCAT used within the analysis. Participants had to be 13 years of age or older, with a diagnosis of concussion from a primary care physician practicing in sport and exercise medicine.

Intervention/Observation Technique: Rasch analysis was performed using RUMM 2030 to assess the SCAT5 symptom evaluation for overall fit, response scaling, individual item fit, differential item functioning, local dependency, unidimensionality and reliability (using the person separation index).

Outcome Measures: Rasch analysis was performed using RUMM 2030 to assess the SCAT5 symptom evaluation for overall fit, response scaling, individual item fit, differential item functioning, local dependency, unidimensionality and reliability (using the person separation index).

Results: The SCAT5 symptom evaluation demonstrated an acceptable fit to the Rasch model, exhibited high reliability and was able to differentiate between at least 4 levels of patients. Nonetheless, serious psychometric issues were identified within the measure. Response dependencies were identified between 15 pairs of items, suggesting a redundancy within these items. Further, 11 items were found to have sex-linked response biases, and the overall scale was found to be multidimensional (suggesting that the SCAT5 symptom evaluation is measuring multiple constructs).

Conclusions: The Rasch model appears unsuitable for psychometric evaluation of the SCAT5 symptom checklist. Methods for addressing these issues will be discussed in the context of leveraging this analysis to create a more reliable and valid tool.

Injury Rates in Amateur Cheerleaders in Saskatchewan

Mikayla Laube, BSc,* Amanda Kleisinger, MD,*,† and Muhammad A. Siddiqui, PhD‡

Affiliations: *College of Medicine (CoM), University of Saskatchewan, Saskatoon, SK, Canada; †Division of Physical Medicine and Rehabilitation, Wascana Rehabilitation Centre, Saskatchewan Health Authority (SHA), Regina, SK, Canada; and ‡Department of Research, SHA, Regina, SK, Canada.

Objective: Explore the correlations between level of “All Star” cheerleading, age, training volume, sleep, and body mass index (BMI) to look for patterns in self-reported injury incidence and prevalence, history of injury, access to health care services, and influence on Cheerleading participation in Saskatchewan.

Study Design: A cross-sectional study conducted via electronic self-report questionnaire.

Subject: “All Star” cheerleading athletes and/or their guardians in Saskatchewan.

Intervention: An email containing the questionnaire link was distributed by the Saskatchewan Cheerleading Association (SCA) to all registered members. The questionnaire had 3 sections: demographics, cheerleading profile, and injury profile.

Outcome Measures: SPSS was used for statistical analysis. Chi-square test, Fisher exact test, t test/Mann Whitney U test, and Hosmer-Lemeshow test were utilized.

Results: Of the 113 participants, 72 reported an injury within the last 2 years. The ankle was most commonly injured (17.7%), stunting was the most common mechanism of injury (36.4%), and 88.7% of injuries occurred during practice. Significant correlations were found between injury occurrence and age group, cheerleading level, BMI, average hours of sleep per night, napping on weekends, and menarche. No signification correlation was found for sex, training hours, sleeping in on weekends, regularity of menstruation, self-reported hypermobility, and dietary restrictions. Family doctors were utilized most frequently (17.6%), and an absence from cheerleading of 2 weeks or less was most common (63.8%).

Conclusions: Several factors were associated with injury occurrence. Consistent with the existing literature were ankle injuries being most common, stunting causing injuries, and more injuries occurring in older athletes at higher levels. This baseline data could be used to target areas for injury prevention. Further studies could be done in Saskatchewan to explore utilization of health care services for rehabilitation, or to test an injury prevention program based on this study's findings.

Feasibility and Reliability of a Novel Game-Based Test of Neurological Function in Youth: The Equilibrium Test Battery

Heather A. Shepherd, MSc OT,* Cody van Rassel, CEP, MKin,* Amanda Black, CAT(C), PhD,*,†,‡ Vineetha Warryiar K.V., PhD,* Robby Graham,* Carolyn A. Emery, PT, PhD,*,†,‡,§,¶ Keith Yeates, PhD,†,‡,§,¶,‖,** and Kathryn J. Schneider, PT, PhD*,†,‡,††

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Alberta Children's Hospital Research Institute, Calgary, AB, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Calgary, Calgary, AB, Canada; §Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; ¶Department of Pediatrics, University of Calgary, Calgary, AB, Canada; ‖Department of Psychology, University of Calgary, Calgary, AB, Canada; **Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; and ††Evidence Sport and Spinal, Calgary, AB, Canada.

Objective: To evaluate the feasibility and test-retest reliability of the Highmark Interactive Equilibrium (EQ) test battery in uninjured youth.

Study Design: Feasibility and reliability study.

Subjects: Fifty-five uninjured (31 females, 24 males, median age = 16, range 14-19) high school students (grades 10-12) in Calgary, Alberta and area.

Observation Techniques: Subjects were asked to complete the self-administered EQ test battery (7 subtests) through an interactive game-based iPad application that assesses balance, cognitive function, and visual function, for 15 consecutive school days.

Outcome Measures: Descriptive statistics were used to summarize baseline characteristics and test scores. Feasibility was evaluated by (1) recruitment rates; (2) retention and follow-up rates; (3) completion of test without assistance; and (4) adverse events reported. Test-retest reliability was evaluated using Bland Altman 95% Limits of Agreement (LOA) on each of the 7 subtests comparing days 2 to 3, 2 to 7, and 2 to 14. Subtests included: rapid scanning [seconds (s)], immediate memory (#/40), delayed memory (#/20), Trail Making “B” (s), digits backwards (#/7), balance (deviation from 0), and reaction time [milliseconds (ms)].

Results: Most participants (n = 40, 73%) completed the EQ test battery for ≥10/15 days. All participants completed the EQ test battery without assistance and no adverse events were reported. LOA were wide for all test points {Rapid scanning (s): [LOA2,3 = −6.37 to 5.36; Mean Difference2,3 (MD2,3) = −0.50 (95% CI −1.33 to 0.32); LOA2,7 = −8.73 to 5.77; MD2,7 = −1.48 (95% CI −2.52 to −0.44); LOA2,14 = −9.80 to 4.41; MD2,14 = −2.70 (95% CI −3.80 to −1.59)], Trail Making “B” (s) [LOA2,3 = −24.60 to 15.52; MD2,3 = −4.54 (95% CI −7.33 to −1.75); LOA2,7 = −8.43 to 6.98; MD2,7 = −12.25 (95% CI −16.10 to −8.40); LOA2,14 = −38.01 to 10.58; MD2,14 = −13.71 (95% CI −17.41 to −10.02)], and reaction time (ms) [LOA2,3 = −115.16 to 48.44; MD2,3 = −33.36 (95% CI −44.75 to −21.98); LOA2,7 = −158.65 to 68.96; MD2,7 = −44.84 (95% CI −61.55 to −28.13); LOA2,14 = −152.36 to 87.79; MD2,14 = −32.28 (95% CI −50.32 to −14.25)]}.

Conclusions: Based on LOAs, the test-retest reliability for some substests are poor across multiple time points. The reliability of the EQ test battery delivered in a school setting requires further research to inform the utility of this test battery following concussion.

Acknowledgments: This study was funded by Highmark Interactive. We would like to acknowledge the participants, teachers and schools for their support in the study. The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee.

Differences in Wrist and Scapular Kinematics When Using Axillary Versus Forearm Crutches

Monica Russell,* Gregor Kuntze, PhD,*,† Shaine Jivan, BSc,* Janet L. Ronsky, PhD,†,‡ and Ranita H. K. Manocha, MD, MSc†,§

Affiliations: *Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada; ‡Department of Mechanical and Manufacturing Engineering, University of Calgary, Calgary, AB, Canada; and §Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.

Objective: Crutches are often prescribed after lower extremity sports injuries. In Canada, the axillary crutch (AC) tends to be used, whereas in Europe, the forearm crutch (FC) tends to be used. Both crutch types require repetitive weight-bearing through the upper extremities (UE). This can result in secondary UE pain and injury, causing further impairment to the injured crutch-using athlete. This investigation aimed to quantify wrist and scapular kinematics during crutch-assisted gait with AC and FC, to determine how each crutch type might result in UE pain or injury.

Study Design: Randomized gait laboratory study.

Subjects: Fifteen healthy able-bodied adult males (mean age: 26; range: 23-34).

Intervention/Observation Technique: Subjects were fit with AC and FC using standard guidelines. Subjects were trained on performing single limb swing-through gait with both crutch types. When they felt comfortable, subjects performed 10 gait cycles with each crutch type. Subjects were randomized to order of crutch type used first. A 12-camera motion capture system captured UE and crutch kinematics. Joint coordinate systems were established using standardized guidelines. Ten trials per crutch type per subject were normalized and averaged. Two-way repeated measures analyses of variance with crutch type and gait cycle as factors were performed for each outcome measure.

Outcome Measures: The primary outcome was wrist flexion/extension angle. The secondary outcomes were scapular upward/downward rotation and wrist radial/ulnar deviation.

Results: The FC produced greater wrist extension (+13 degrees, P < 0.01) and ulnar deviation (+7 degrees, P = 0.04) throughout the gait cycle compared to axillary crutches. Although scapular downward rotation was higher with FC, this did not reach statistical significance (−3 degrees, P = 0.09).

Conclusions: Although forearm crutches allow the user to keep the crutches anchored to the body while using their hands, their use results in increased wrist extension and ulnar deviation compared to axillary crutches. This may explain why cases of ulnar stress fractures and ulnar neuropathies at Guyon canal have been reported with FC use. Although AC use has been reported to cause rotator cuff tendinopathy and suprascapular neuropathy, this investigation showed FC would increase strain on these structures compared to AC. In terms of the scapula and the wrist, FC appear to increase risk of UE discomfort compared to AC.

Acknowledgments: Cumming School of Medicine Clinical Research Fund Grant (CRF18-1202).

Self-Reported 1-Year Physical Activity Participation, Injury, and Illness in Canadian Adolescent Ski Racers

Patricia K. Doyle-Baker, PH/PhD,*,†,‡ and Carolyn A. Emery, PhD, PT*,‡,§

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †School of Architecture, Planning and Landscape, University of Calgary, Calgary, AB, Canada; ‡Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; and §Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: The Training and Competition Matrix in the redesigned Canadian Alpine LTAD identifies volumes and quantities associated with performance programs, but not physical activity outside the ski training paradigm. Therefore, the objectives were to describe: (1) physical activity participation, type and volume and (2) injury and health indicators from the previous 12 months in adolescent racers registered in the Alberta Alpine Ski Association.

Design: Cross-sectional study.

Subjects: Parents of alpine racers (5 clubs; n = 52 F; n = 44 M; ages 9-14 years) completed a baseline medical questionnaire at the 2017 preseason training.

Outcome measures: Self-reported physical activity and health outcomes are described as rates, means, or frequencies (%).

Results: The mean number of activities for participation was 5 (range 1-14) and the most frequently reported were cycling, hiking, and swimming. A cumulative activity mean of just under 400 hours was reported with ranges differing between males (62-868) and females (27-1015). Over the past 12 months, 22.8% of the athletes reported being injured and injury severity impacted return to sport with a range of reported time loss from 1 to 60 days. Thirteen injuries occurred in alpine skiing and females (11.5%, 6/52) reported more lower limb injuries than males (6.8%, 3/44). Athletes (85%) did not take medication on a regular basis and those that did reported a medical diagnosis. The frequency of diagnosed respiratory conditions were 12.6% (12/95) with males reporting slightly more cases than females. No difference in emergency visits were reported (25%) between males and females in the past 12 months however, more visits to allied health care and sport medicine physicians occurred with females (102) when compared to males (n = 65).

Conclusions: A high volume of physical activity (over an hour per day) was reported over the previous 12 months in 10 to 14 year old Alpine ski racers. Ski coaches should consider the inclusion of all physical activity when calculating total volume of load in young racers who are entering a transition period of growth and increased risk of overuse injury. Employing wearable technology to quantify intensity and participation hours in combination with the self-report questionnaire would improve the accuracy of the data collected.

A 3D Motion Capture Analysis of an Accidental Lateral Ankle Sprain Injury During a 180-Degree Pivot Turn

M. Chin,* M. Leppänen, PhD,† J.-P. Kulmala, PhD,‡ J. Parkkari, MD, PhD,† T. Vasankari, MD, PhD,† and K. Pasanen, PT, PhD*,†,§,¶

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, Calgary, AB, Canada; †Tampere Research Centre of Sports Medicine, UKK Institute, Tampere, Finland; ‡Motion Analysis Laboratory, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; §Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; and ¶McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.

Objectives: To examine the mechanics of a lateral ankle sprain injury using 3D motion capture on a female ice hockey player.

Study Design: Case Study.

Subjects: This case study was on an elite female ice hockey player (160 cm, 57 kg, 18 years old, left foot dominant) with no prior injury history to the injured ankle (right).

Observation Techniques: The study was conducted in a 3D motion capture laboratory using an 8-camera system and 2 force platforms. A 16 retroreflective marker set was used for this study. Three trials looking at a 180-degree pivot turn were analysed (one was the injury trial and 2 were control trials). Analysis was conducted on the contact leg which suffered a lateral ankle sprain (right).

Outcome Measures: Angles (degrees) were analysed between the accident trial and 2 control trials for plantarflexion, inversion, and internal rotation. Peak angles were also identified for each movement.

Results: Peak plantarflexion angle was 36-degrees in the injury trial (in comparison to 18- and 19- degrees for the 2 control trials). Inversion angle at initial contact was 9-degrees greater and peak internal rotation angle 40- and 45-degrees greater in the injury trial compared to control trials 1 and 2, respectively.

Conclusions: This study provided detailed description of mechanism of lateral ankle sprain. The injury involved increased ankle inversion, internal rotation and plantarflexion angles prior to initial contact. In future studies, analysis of ankle and knee movements and forces, as well as the influence of approach velocity, need to be conducted.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. The Tampere Research Center of Sports Medicine is one of the 6 centers of Sports and Exercise Medicine in Finland, which aims to promote a healthy lifestyle and physical activity. The study was financially supported by the Finnish Olympic Committee, Finnish Ministry of Education and Culture, and Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital.

Resource Utilization in Clinically Suspected Rotator Cuff Tears at First Presentation: A Retrospective Observational Study

Jordan Anderson, MD, Scott Shallow, MD, and Matt Simpson, MD

Affiliation: Queen's University, Kingston, ON, Canada.

Objective: We aimed to determine whether Canadian family physicians adhere to evidence-based guidelines when investigating clinically suspected rotator cuff tears. We also sought to estimate the time and cost savings of implementing guidelines in this clinical scenario.

Study Design: Retrospective chart review.

Subjects: One hundred five subjects (54 females, 51 males) diagnosed with suspected rotator cuff tears.

Observation Technique: Patients >18 years old seen at the Queen's Family Health Team (QFHT) academic family medicine practice between October 1, 2017 and September 30, 2019 who were billed with a diagnostic code of 840 (Sprain, Shoulder) or 727 (Bursitis, Tendonitis) for the first time in that patient's history. Charts were reviewed to ensure they met appropriate criteria for clinically suspected rotator cuff tear.

Outcome Measures: Completion of X-Ray, ultrasound, or MRI requisition on the date of the associated patient encounter; completion of referral to specialist.

Results: 54.2% (57/105) of encounters had no imaging requisition completed. X-Rays alone were ordered in 7.6% (8/105) while ultrasound alone was ordered in 21.9% (23/105) of encounters. Both X-Ray and ultrasound requisitions were completed in 16.2% (17/105) of encounters. No patients were given a requisition for MRI, and one patient was sent to a specialist at the first visit. 87.5% (42/48) of encounters where patients received imaging did not follow evidence-based guidelines. Thirty-nine ultrasounds and 3 X-Rays were deemed to be ordered in excess, resulting in over 11 hours and $780 in potential cost-savings.

Conclusions: In practice, Canadian family physicians do not routinely follow evidence-based imaging guidelines when investigating clinically suspected rotator cuff tears, which results in excess financial and time costs to our health care system.

Establishing the Minimal Clinically Important Difference (MCID) for the Adult Version of the Sport Concussion

Michael Robinson, PhD, CAT(C), ATC, Lisa Fischer, MD, Andrew Johnson, PhD, David Walton, PhD, PT, and Joy MacDermid, PhD, PT

Affiliation: Western University, London, Ontario.

Objective: This study aimed to determine the responsiveness of the SCAT5 symptom evaluation checklist, and to estimate the minimal clinically important differences for each of the 22 symptoms.

Study Design: Single Site—Primary Care Setting.

Subjects: A total of 125 subjects were included (72 males, 53 females mean age 18.64 ± 8.66). All subjects were 13 years of age or older and had been diagnosed with a concussion by a primary care physician practicing in sport and exercise medicine.

Intervention/Observation Technique: The SCAT5 symptom evaluation was administered to patients as a component of their routine clinical encounter and the presence and severity (measured on a 7-point Likert scale from 0 to 6) of each of the 22 symptoms was included in the analysis.

Outcome Measures: Minimal Clinically Important difference (MCID), Minimal Detectable Change (MDC) and Standardized Response Mean (SRM) 22 symptoms, total symptom score and total number of symptoms endorsed.

Results: Overall, the SCAT5 symptom evaluation was highly responsive, with all of the SRM estimates displaying a large effect. The magnitude of the SRM estimates suggests that the SCAT5 symptom evaluation is sensitive to changes in concussion symptom severity.

Conclusions: The MDC estimates for all 22 symptoms, the total symptom score and the total number of symptoms endorsed were all lower than the associated MCID estimates therefore the MCID estimates are a true representation of clinical change.

Identifying the Barriers and Facilitators to the Implementation of Neuromuscular Training for ACL Injury Prevention in Canadian Youth Soccer

Meghan C. M. Crookshank, MD, PhD, Babak Aliarzadeh, MD, MPH, and James Carson, MD

Affiliation: Department of Family and Community Medicine, Scarborough Health Network, University of Toronto, Toronto, ON, Canada.

Objective: The Canadian Academy of Sport and Exercise Medicine released a position statement in 2014 with the recommendation that neuromuscular training (NMT) be routinely incorporated into training and pregame warm-ups for youth soccer teams. It is unclear to what extent this has been adopted by Canadian soccer associations (SAs). This study aims to identify barriers and facilitators to using NMT by Canadian SAs.

Study Design: Cross-sectional survey.

Subjects: Surveys were distributed to representatives from SAs across Canada. Fifty-two responses were received and, based on completion of survey and consent, the final sample was 46 participants.

Observational Techniques: Surveys were anonymous with no identifying information. They were distributed using a snowballing sampling strategy.

Outcome Measures: Survey questions covered the domains of knowledge, attitudes, and behaviours regarding the use of NMT in Canadian youth soccer. This included questions regarding their knowledge of NMT programs and opinions with respect to the current use of NMT in their association and the perceived barriers and incentives for NMT. Nominal variables were analyzed with respect to the frequency and percentage of responses with uncertainty expressed as the 95% confidence interval (CI).

Results: Responses were received from 6 of the provinces/territories. Sixty-three percent (CI 48.6%-75.5%) had heard of NMT and 47.8% (CI 34%-61%) had received advice regarding NMT from a higher-level body, such as the provincial/territorial soccer association. The main perceived barriers to implementation were the lack of knowledge, lack of training for coaches, and the time required for NMT prior to matches/training. The main perceived benefits of NMT were a decreased risk of ACL injury, additional performance benefits for the athletes, and the low implementation cost.

Conclusions: This study illustrates the existing gap between the evidence supporting NMT and its implementation in Canadian youth soccer. It, additionally, illustrates that there is a willingness and interest in NMT from members of youth SAs. Thus, this study emphasizes the need for organized knowledge dissemination to youth SAs to achieve higher rates of NMT.

Long-Term Effects of Multiple Concussions on Cerebrovascular Reactivity in Retired Contact Sport Athletes

Luke W. Sirant, BKin,* Jyotpal Singh, MSc,* Steve Martin, MD,† Catherine A. Gaul, PhD,† Lynneth Stuart-Hill, PhD,† Cameron Bowers, MSc,† Jake Bryan, BSc,† and J. Patrick Neary, PhD*

Affiliations: *University of Regina, Faculty of Kinesiology and Health Studies, Regina, SK, Canada; and †University of Victoria, Faculty of Exercise Science, Physical and Health Education, Victoria, BC, Canada.

Objective: To explore the long-term effects of prior concussions on cerebrovascular reactivity to carbon dioxide using near-infrared spectroscopy (NIRS) in physically active retired athletes.

Study Design: Cross-sectional study.

Subjects: Thirty-eight physically active males participated. Nineteen (mean age = 63 ± 7 years) had a history of ≥3 previous concussions (PC) were age matched to 19 (mean age = 64 ± 9 years) with no history of previous concussions (NPC). All participants had been contact sport athletes in their youth and/or young adulthood.

Intervention: All subjects completed a 5-minute seated rest to establish physiological baseline, followed by a 5-minute hypercapnic challenge protocol to assess changes in cerebrovascular reactivity. Hypercapnic challenge consisted of a 20-second breath-hold followed by 40-seconds of normal breathing repeated 5 times without breaks. Expired respiratory gases were recorded to confirm hypercapnia.

Outcome Measures: NIRS was used to measure cerebral haemodynamics in both the right and left prefrontal cortices during rest and the hypercapnic challenge. NIRS measures included: oxygenated (HbO2), deoxygenated (HHb), total (tHb) haemglobin, and haemoglobin difference (HbDiff). Variables were analysed by observing the change between the maximal and minimal values ([INCREMENT]MAX) for each NIRS variable during the 20-second breath hold. Independent Student t-tests were used to compare each NIRS variable in the PC versus NPC.

Results: Right HbDiff [INCREMENT]MAX was significantly (P = 0.04) higher in PC (mean = 1.53 ± 0.65 μM) versus NPC (mean = 1.15 ± 0.65 μM). Left HbO2 [INCREMENT]MAX was also significantly (P = 0.04) greater in PC (mean = 1.50 ± 0.66 μM) versus NPC (mean = 1.11 ± 0.66 μM). Left HbDiff (P = 0.07), right HbO2 (P = 0.054), as well as HHb (right: P = 0.14; left: P = 0.23) and tHb (right: P = 0.08; left: P = 0.08), all trended towards greater mean values in the PC versus NPC though did not attain statistical significance.

Conclusions: Compared to the NPC, the increased left prefrontal cortex HbO2 and right prefrontal cortex HbDiff in the PC during the 20-second breath-hold challenge indicates a greater metabolic demand in response to the accumulation of CO2, requiring a greater amount of cellular oxygen consumption. These findings provide preliminary evidence that there are long lasting differences in brain autoregulatory systems, specifically cerebrovascular reactivity observed in this study, due to previously sustained concussions.

Acknowledgments: CASEM for research funding.

Quadriceps Strength as a Predictor of Mortality in Older Patients With Heart Failure

Kentaro Kamiya, PT, PhD,* Takeshi Nakamura, PT, MSc,† Nobuaki Hamazaki, PT, PhD,‡ Kohei Nozaki, PT, MSc,‡ Takafumi Ichikawa, PT,‡ Masashi Yamashita, PT, MSc,† Emi Maekawa, MD, PhD,§ Minako Yamaoka-Tojo, MD, PhD,* Atsuhiko Matsunaga, PT, PhD,* and Junya Ako, MD, PhD

Affiliations: *Department of Rehabilitation, School of Allied Health Sciences, Kitasato University Sagamihara, Japan; †Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan; ‡Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan; and §Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan.

Objective: This study was performed to investigate the quadriceps isometric strength (QIS) cutoff for predicting slow gait speed and its prognostic value in patients with heart failure (HF).

Study Design: Retrospective cohort study.

Subjects: A total of 1273 patients ≥ 60 years old with HF (mean age 73.1 ± 7.6 years, 66.7% male), in all of whom usual gait speed and maximal QIS had been evaluated during hospitalization.

Observation: QIS was expressed relative to body weight (%BW). The QIS cutoff value for slow gait speed (≤0.8 m/s) was analyzed using the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

Outcome Measures: The outcome was all-cause mortality.

Results: QIS was independently associated with gait speed, and the QIS cutoff for slow gait speed was 37.0% BW (AUC = 0.78). Over a median follow-up period of 1.59 years (interquartile range, 0.58-3.42 years), 224 patients died. Higher QIS was associated with reduced all-cause mortality (hazard ratio for 10% BW increase of QIS 0.85, 95% confidence interval 0.76-0.96) after adjusting for other prognostic factors, and was also associated with reduced all-cause mortality across various subgroups.

Conclusions: QIS of 37.0%BW was useful for predicting slow gait speed in patients with HF. Moreover, higher QIS was strongly associated with favorable prognosis in older patients with HF. QIS is useful in risk stratification of HF patients and for defining strength training goals in cardiac rehabilitation for frailty patients.

Feasibility of a Coaching App in the Management of Patients With Post-concussion Symptoms

Julia Lauzon,* Dorothyann Curran, MHSc,† Deanna Quon, MD,† and Shawn Marshall, MD, MSc*,†

Affiliations: *University of Ottawa, Ottawa, ON, Canada; and †The Ottawa Hospital Rehabilitation Centre, Ottawa, ON, Canada.

Objective: Patients with persisting mTBI/concussion symptoms can experience significant somatic, social, economic and psychological impacts. Following specialist consultations, patients often exhibit challenges with treatment recommendations, including medication and lifestyle modifications. An internet-based health coaching tool may allow for more timely and consistent patient contact, which could provide the support needed to help patients optimize their health outcomes. Our objective is to assess the feasibility of a scheduled interactive personal health log with a coaching component, in the management of patients with post-concussion syndrome.

Subjects: Seven patients were recruited as new consultations from The Ottawa Hospital Rehabilitation Centre post-concussion clinic.

Study Design: To use the App and track 2 to 4 individual treatment goals derived from their initial consultation, for 5 to 6 weeks. Patients completed weekly progress questionnaires and the health coach and physician provided scheduled weekly health coaching, through the App. Data collected included patient App activity/compliance, patient satisfaction and feedback, physician and coach satisfaction, and pre and post symptom comparison using the Rivermead post-concussion symptom questionnaire.

Results: All questions received scores of “Strongly Agree,” “Agree” or “Neither Agree nor Disagree” from all participants, with most responses being positive. All participants found the App easy to use, and 5 participants (71.4%) felt that the coaching and App helped them improve their symptoms. All participants believe that this is an effective tool that could be used in patient care. Six out of 7 patients (85.7%) had improved scores on their Rivermead Post-Concussion Questionnaire after the 6 weeks. Six out of 7 patients showed a compliance of 90% or higher with using the app.

Conclusion: Our results show promising evidence that an online coaching App is a feasible tool to improve the adherence and symptom management of patients with post- concussion symptoms. Further studies should focus on determining the effectiveness of this intervention on a larger scale.

Advocacy for the Child in Sport

Chantelle Hanley, MSc* and Gwyneth de Vries, MD†

Affiliations: *Educator, Coaching Association of Canada, ParaNB, Fredericton, NB and Charlottetown, PE; and †Department of Clinical Neurosciences, Horizon Health Network, Fredericton, NB, Canada.

Objective: Canadians, including children, understand the health benefits of sport. Increasingly, children are aware of their rights in sport but may need special advocacy in the event of experiencing harms in the course of their participation. This study aims to explore the extent to which offices of child and youth advocates may provide assistance to the child athlete.

Data Sources: Online government websites, documents, policy statements, and related publications for all 10 provinces and 3 territories of Canada were searched. Full texts were reviewed and items of interest were tabulated.

Main Results: Child and youth advocacy in Canada is widespread but not universal. Two provinces (Ontario and Nova Scotia) place child advocacy under an ombud office; the Northwest Territory does not have a Child Advocate office. The remaining 8 provinces and 2 territories have an office for child/youth advocacy. Offices universally refer to the United Nations Convention on Rights of the Child (UNCRC) as a foundational document. The maximum age of “child” ranges from 16 to 21 nationally. Only 2 offices (British Columbia and New Brunswick) return information to online search queries of “sport” or “athlete.” No office provides a link to the Canadian Sport Helpline. Currently, only one province (New Brunswick) recommends a commitment to “a comprehensive review of all domestic legislation, regulations, policies and government practices to ensure full compliance with the [UNCRC].”

Conclusions: Sport imparts positive lifetime health benefits for children. The UNCRC outlines the highest level of advocacy for the right to reach physical potentials and for protection from harms along the way. Relevant and up-to-date sport principles are evident in our provinces/territories but translation to childhood sport advocacy lags behind; children are vulnerable to the normalization of physical and psychological harms too often seen in sport. Present variability and deficiencies in child-specific provincial governance in sport (eg, accountability) creates confusion and may thwart or halt participation in sport, leading to loss of health benefits. Designation of sport within Child Advocacy may better address inevitable injuries or avoidable harms and still allow promotion of activity (including organized sport) to benefit children.

A Biomechanical Comparison of Knee Braces With Application for Posterolateral Corner Reconstructions

Kirsten Hickie, MD,* Yuelin Qiu,† Mark Sommerfeldt, MD,* Stephanie Nathanail, BPE,* and Lindsey Westover, PhD‡

Affiliations: *Division of Orthopaedic Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada; †Department of Civil Engineering, University of Alberta, Edmonton, AB, Canada, Alberta; and ‡Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada.

Objective: To determine the stiffness of 6 different types of knee immobilizer braces under varus force. The data collected will be used to establish a postoperative protocol for operatively treated posterolateral corner injuries.

Study design: This is a biomechanical study testing the stiffness of different types of knee immobilizers at 5, 8, and 12 degrees of varus bend.

Intervention: Six different knee immobilizers were studied: straight cruciate, medial unloader, cruciate with a valgus bend, hinged, articulating sleeve, and tri-panel knee immobilizer. There were 3 in each group except for straight cruciate (n = 2), and medial unloader (n = 2). Each brace was fitted to the same fiberglass leg model and secured to the model proximally and distally. A one-inch area of fiberglass was cut out at the level of the knee to allow for movement with force application, in order to isolate the stiffness of the knee immobilizer. Forces were applied at the level of the thigh and the ankle under 4-point bending to generate a varus moment about the knee.

Outcome Measures: The stiffness (N/mm) of each immobilizer was calculated from the slope of the force-displacement curve at 5, 8, and 12 degrees of varus.

Results: Of the braces tested, at 5 and 8° varus bend, the articulating sleeve brace was significantly stiffer than the rest of the braces (P < 0.05). At 12° varus bend, no significant difference was found between the groups and large standard deviations were found. Results from the additionally required brace types (one straight cruciate and one medial unloader) will be obtained.

Conclusions: In this experimental design the sleeve brace seems to have the highest stiffness. Whether this translates into clinical performance is uncertain and further research is required.

Acknowledgments: Operating Grant provided by The Edmonton Civic Employees Research Award.

Knee Immobilizer Braces Donated by Procare Medical Designing an e-Module for Family Medicine Residents on Physical Activity in Pregnancy

Aakriti Pyakurel, MPA,* Lisa Kachaniwsky, BSc,*,‡ Sarah Whyte, PhD,* Rachel McDonald, BSc,† Sophie Glanz, BSc,† and Karen Fleming, MD*,†

Affiliations: *Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; †Faculty of Medicine, University of Toronto, Toronto, Canada; and ‡Canadian College of Naturopathic Medicine, Toronto, Canada.

Objective: Physical activity in pregnancy confers many benefits to 2 generations by reducing the risk of gestational diabetes, hypertensive disorders of pregnancy; and improving physical and psychological well-being in pregnancy. Physician counselling has been shown to increase patient participation in physical activity; however, many physicians do not provide exercise counselling and receive no formal training on this topic.

The objective of this study is to design an effective online module (e-module) to increase family medicine residents' knowledge of physical activity in pregnancy and their confidence in providing exercise counselling to patients.

Study design: This is a qualitative study on designing an online educational intervention using Articulate Storyline software for family medicine residents at a tertiary care center in Toronto, Canada. The design involves rigorous literature search, focus group session with residents, expert feedback, and the evaluation of the module.

Subjects: N/A.

Intervention: An online based module on physical activity in pregnancy with didactic and interactive case-based elements on: (1) Health benefits and potential risks of physical activity in pregnancy to both mother and baby; (2) New guidelines and available tools for counselling pregnant women about physical activity and pregnancy; and (3) Strategies to implement physical activity prescription using updated exercise in pregnancy guidelines across different patient populations.

Outcome measures: Observation of residents' e-module completion while talking aloud about their thought process; and assessment of residents' perceptions on the content, educational value, design, and ease of use through one-on-one interviews.

Results: The focus groups with residents identified liked and disliked features. Liked features included self-paced, interactive games, less than 30 minutes in length, and videos demonstrating counselling. The pilot of the initial module with residents identified primary areas of improvement: additional videos demonstrating physician-patient counselling, “Key messages” slides, detailed explanations for quizzes, and address technical glitches. The next step is to conduct formal evaluation of the modules with residents to inform the final e-module modifications.

Conclusions: This resource has the potential to provide family medicine residents with effective learning materials on physical activity in pregnancy. In the future, the e-modules can be shared with other sites and providers involved with maternal care.

Disease Definition and Diagnostic Pathway of Deep Gluteal Syndrome: A Systematic Review

Kazuha Kizaki, MD, MSc,*,‡ Soshi Uchida, MD, PhD,† Ajaykumar Shanmugaraj, BSc,‡ Camila Catherine Aquino, MD, MSc,* Andrew Duong, MSc,‡ Nicole Simunovic, MSc,*,‡ Hal David Martin, DO,§ and Olufemi R. Ayeni, MD, MSc, PhD*,‡

Affiliations: *Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; †Department of Orthopaedic surgery, Wakamatsu Hospital for the University of Occupational and Environmental Health, Kitakyushu, Japan; ‡Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada; and §Hip Preservation Center, Baylor University Medical Center at Dallas, Dallas, Texas.

Objectives: The diagnosis of deep gluteal syndrome (DGS) is a clinical diagnosis that clinicians are not confident with making because of the ambiguity of the DGS disease definition and DGS diagnostic pathway. The purpose of this systematic review was to identify the DGS disease definition, and also to define a general DGS diagnostic pathway.

Data Sources: We conducted a systematic search using 4 electronic databases: PubMed, MEDLINE, EMBASE, and Google Scholar. In eligibility criteria, we included studies in which cases were explicitly diagnosed with DGS, whereas review articles and commentary papers were excluded. Data are presented descriptively.

Main Results: The initial literature search yielded 359 articles, of which 14 studies met the eligibility criteria, pooling 853 patients with clinically diagnosed with DGS. In this review, it was discovered that the DGS disease definition was composed of 3 parts: (1) non-discogenic; (2) sciatic nerve disorder; and (3) nerve entrapment in the deep gluteal space. In the diagnosis of DGS, we found 5 diagnostic procedures: (1) history taking; (2) physical examination; (3) imaging tests; (4) response-to-injection; and (5) nerve specific tests (electromyography). History taking (eg, posterior hip pain, radicular pain, difficulty sitting for 30 minutes), physical examination (eg, tenderness in deep gluteal space, pertinent positive results with seated piriformis test and positive Pace sign, and imaging tests (eg, spine and pelvic magnetic resonance imaging) were generally performed in cases clinically diagnosed with DGS.

Conclusions: Existing literature suggests the DGS disease definition as being a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space. Also, the general diagnostic pathway for DGS was composed of history taking (posterior hip pain, radicular pain, difficulty sitting for 30 minutes), physical examination (tenderness in deep gluteal space, seated piriformis test and positive Pace sign), and imaging tests (spine and pelvic magnetic resonance imaging).

Workload A-Wear-ness: Monitoring Workload in Team Sports With Wearable Technology—A Systematic Review and Meta-analysis

Lauren Benson, PhD,* Anu M. Räisänen, PT, PhD,* Valeriya G. Volkova,* Kati Pasanen, PT, PhD,*,†,‡,§ and Carolyn Emery, PT, PhD*,‡,§,¶,‖

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

Objective: To summarize the characteristics of the studies and athletes for which workload data has been reported; to examine trends in wearable devices and workload metrics; and to evaluate the strength of the workload-injury relationship.

Data sources: MEDLINE, CINAHL, Cochrane Controlled Register of Trials, Cochrane Reviews, EMBASE, HealthStar, PsycInfo, Sport Discus, and Web of Science databases were searched for studies that monitored team sport athlete workload using wearable devices in a team sport setting. Two reviewers conducted a title, abstract, and full-text review of eligible studies, with a third author as the tiebreaker. Inclusion and exclusion criteria were applied to the searched studies, data were extracted, and a quality assessment was completed for included studies.

Results: The included research (339 studies) had a narrow focus regarding the sports (70% soccer, rugby or Australian football), athlete sex (82% male), competition level (75% elite or professional) and age (84% between 20 and 28 years). Wearable technology has facilitated workload monitoring over multiple seasons, yet 55% of studies recorded fewer than 25 sessions per participant. Recent studies use multiple sensors to monitor workload, however, a lack of consensus on workload metrics limits the ability to assess the workload-injury relationship. Just the results of 4 studies involving elite male soccer players could be combined in meta-analyses examining the effect of cumulative total distance and high-speed distance on the odds of injury (odds ratio; OR), with only the 1-week total high-speed distance of between 634 and 1449 m associated with a significant odds of injury (OR: 1.52, 95% CI: 1.09-2.14) compared to lower total high-speed distance.

Conclusions: The use of wearable technology to monitor workload is growing rapidly. Expanding on this research in females, different sports, ages, and competition levels will lead to better understanding of workload patterns in team sport athletes. In contrast, the large number of possible workload metric and accumulation combinations limits the ability to assess the effect of workload on injury risk. Future research should consider standardized measures of workload quantity, perhaps within the population of interest, so that the workload-injury relationship can be compared across studies.

Acknowledgments: Matt Jordan, PhD for assistance with developing the framework for this review. The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee.

Narcotic Prescriptions Following Knee and Shoulder Arthroscopy: A Surgeon Survey

Seper Ekhtiari, MD,* Nolan S. Horner, MD,* Ajaykumar Shanmugaraj, BHSc,† Andrew Duong, MSc,‡ Nicole Simmunovic, MSc,* and Olufemi R. Ayeni, MD, PhD, FRCSC†,‡

Affiliations: *Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; †Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; and ‡Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.

Objective: Our objectives were: (1) To establish an understanding of opioid prescribing patterns by surgeons for post-operative pain control for patients undergoing elective knee and shoulder arthroscopy; (2) To determine if Canadian surgeons believe they or other surgeons are on average over prescribing opioid medications after knee and shoulder arthroscopy; and (3) Identify what non-opioid pain management strategies surgeons are regularly using after knee and shoulder arthroscopy.

Study Design: Survey.

Subjects: Physicians who perform knee and shoulder arthroscopy.

Outcome Measures: Following validation by the focus group, the final survey (23 questions) was e-mailed to members of the Arthroscopy Association of Canada (AAC) (n = 99).

Results: A total of 38 responses were included (38.3%) from members of the AAC. Responses were received from surgeons in all provinces of Canada. Eighty-two percent of surgeons felt that opioid over prescription was an issue in arthroscopic surgery. The average post-operative knee or shoulder arthroscopy prescription included a total of 156 ± 84.4 (0-400) mg of oral morphine equivalents (OMEs). Less than one-third of all respondents (29%) had received formal peri-operative pain management training. More than half (55%) of respondents felt that non-opioid medications do not provide adequate pain relief after arthroscopic surgery. Nearly all respondents (95%) stated that they would change their current post-operative prescription practice if high quality evidence were to suggest that they should do so.

Conclusions: The majority of Canadian surgeons have identified opioid over prescription as a problem after arthroscopic surgery. On average surgeons are prescribing almost 5 times the amount of OMEs to patients that previous literature has suggested the median patient actually uses after arthroscopic knee surgery. Surgeons report variable use of other pain reduction modalities such as intra-articular injections, cryotherapy and nerve blocks. There is clear clinical equipoise as to whether non-opioid pain medications would provide adequate pain relief to patients after shoulder and knee arthroscopy. However, almost all surgeons state that they would be willing to reduce or eliminate opioid prescriptions to arthroscopy patients if high level evidence were to emerge suggesting that adequate pain control could be achieved without the use of narcotics.

Platelet-Rich Plasma for the Management of Osteoarthritis: A Case Series

Aden M. Mah, BSc,* Zachary M. Oleynik, BEd,† Megan D. Dash, BSc, MD,‡ and Jeremy G. R. Reed, MD§

Affiliations: *University of Saskatchewan College of Medicine, Saskatchewan, SK, Canada; and †Dash & Reed Sports Medicine Clinic, White City, SK, Canada.

Objective: To determine patient satisfaction and subjective improvement in function following Platelet-Rich Plasma (PRP) therapy for the management of osteoarthritis (OA).

Study Design: Retrospective, case series.

Subjects: Forty patients (21 female and 19 males) who received PRP therapy for osteoarthritis at Dash & Reed Sports Medicine clinic.

Intervention: PRP therapy from Dash&Reed sports medicine clinic.

Outcome Measures: Outcome measures were obtained via retrospective telephone interviews from Dash & Reed Sports Medicine clinic. The primary outcome measure was patient satisfaction with PRP therapy, assessed via 2 yes or no questions. The secondary outcome measure was patient subjective improvement in function following PRP therapy, assessed via baseline SANE score, post-PRP SANE score, and an activities of daily living (ADL) functionality question.

Results: There was a significant difference in baseline SANE score compared to post-PRP SANE score, from 40 to 73 respectively (P < 0.001). The average duration of symptom relief was 7 months. Sixty percent of patients report improvements in their ability to do ADLs following PRP therapy, 85% of patients were glad that they had the procedure done, and 60% would have it done again.

Conclusions: Patients report significant improvements in OA symptoms following PRP therapy. Though limited by a small sample size and single center research site, findings from this study support that patients are overall satisfied with PRP therapy for the management of their osteoarthritis symptoms.

Outcomes of Management Options of Pathology of the Long Head of Biceps Humerii: A Chart Review

Aden M. Mah, BSc,* Zachary M. Oleynik, BEd,† Mitchell D. Thatcher, BSc,‡ Stephen E. Patrick, BSc,§ Megan D. Dash, BSc, MD,¶ and Jeremy G. R. Reed, MD‖

Affiliations: *University of Saskatchewan College of Medicine, Saskatchewan, SK, Canada; and †Dash & Reed Sports Medicine Clinic, White City, SK, Canada.

Objective: To understand which surgical management technique provides the most favourable outcomes in patients with pathology of the long head of biceps tendon (LHBT).

Study Design: Retrospective chart review and follow-up telephone interviews.

Subjects: Two hundred fifty-seven patients (154 male and 103 females) who underwent LHBT surgery with the senior author at least 1 year ago. Patients who received concomitant rotator cuff repair were also included.

Intervention: We compared patients who received tenotomy (n = 114) and tenodesis (n = 143) of the LHBT. We also compared 4 different tenotomy techniques and 3 different tenodesis techniques, for a total of 7 different surgical subgroups. The tenotomy subgroups were: (1) arthroscopic tenotomy (n = 8); (2) arthroscopic shortening and tenotomy (n = 46); (3) arthroscopic tenotomy with mini-open shortening (n = 16); and (4) arthroscopic tenotomy with mini-open shortening and biceps groove debridement (n = 44). The tenodesis subgroups were: (5) arthroscopic tenotomy with mini-open tenodesis drawn in (n = 18); (6) arthroscopic tenotomy with mini-open tenodesis pushed in (n = 99); and (7) arthroscopic tenotomy with mini-open tenodesis pushed in and bicep groove debridement (n = 26).

Outcome Measures: The primary outcome measure was the requirement for further intervention following the LHBT surgery (cortisone injection or another surgery). Primary outcome measures were obtained through a retrospective chart review. The secondary outcome measure was patient satisfaction and subjective restriction in function following the surgery. Secondary measures were obtained via retrospective telephone interviews using a SANE score question, 2 yes-or-no questions, and a functionality ranking question.

Results: Our primary outcome measure demonstrated a significant difference in post-operative intervention between the tenotomy and tenodesis groups (3% vs 11% respectively, P < 0.05). There were no significant differences in post-operative intervention requirement, patient satisfaction, or subjective restriction in function between the 7 surgical subgroups.

Conclusions: Results from this study suggest that LHBT tenodesis may result in higher rates of post-operative intervention compared to tenotomy. Although advancements in technology have evolved surgical techniques over time, there is no superiority of biceps tenotomy or tenodesis subgroups in the treatment of LHBT pathology.

Rosetta Stone Translation Project for Sports Medicine

N. Dilworth, MB Bao, BCh, MScCH,*,†,‡,§,¶ F. O'Leary, MB BAO, BCh, MScClinEd MScSEM,‖ K. Asem, MD,** W. Clayden, MD,†† M. Leung, MD, MScCH,*,‡ J. Niu, MD,‡‡ O. Giollagain, MB BAO, BCh,§§ B. Marekic,‡ S. Ormonde,‡ S. Miajuachi,¶ M. Meijlander-Evjensvold, MB BAO, BCh,¶¶ H. Alshabanah, MD,† Y. Hegazy,‖‖ R. Jang,*** and R. Sugrue, MB BAO, BCh MPH***

Affiliations: *University of Toronto, Toronto, ON, Canada; †Halton Healthcare, Georgetown, ON, Canada; ‡Cleveland Clinic Canada, Toronto, ON, Canada; §William Osler Hospital System, Toronto, ON, Canada; ¶Toronto Football Club, Toronto, ON, Canada; ‖Sport Ireland Institute, Ireland; **Western University, London, ON, Canada; ††McMaster University, Hamilton, ON, Canada; ‡‡University of Ottawa, Ottawa, ON, Canada; §§University College Dublin, Dublin, Ireland; ¶¶Oslo University Hospital, Ullevaal, Oslo, Norway; ‖‖York University, Toronto, Ontario, Canada; and ***Harvard University, Cambridge, Massachusetts.

Objective: To create a translation guide for improving medical-care communication with non-english speaking athletes at sporting events.

Study Design: Qualitative study and sports medicine term translation.

Subjects: Practicing sports medicine physicians from 3 different countries as well as physicians and allied healthcare professionals with linguistic expertise.

Observation Technique: An interview or email conversation occurred with 6 practicing sports medicine physicians for terms that would be helpful in communicating field-side with a non-English speaking athlete. Once the interview/email reached a saturation point (no further terms) with a subject that interview was closed.

Outcome Measures: Six sports medicine physicians were interviewed about what terms and phrases would be helpful to conduct field-side translations with a non-english speaking athlete. The recommended terms and phrases were recorded until subsequent interviews revealed no newer terms or phrases. These terms and phrases were assembled into a single translation template and provided to proficient foreign language speakers for translation.

Results: Sports medicine term saturation occurred at 59 terms by the fifth physician. Phrase saturation occurred by the fifth physician at 26 phrases and questions. These terms and phrases were then used to generate a basic template for a translation guide by healthcare professionals with proficiency in the following languages: French, German, Irish, Japanese, Mandarin, Norwegian, Portuguese, Serbian, and Spanish (Arabic and Korean pending).

Conclusions: One of the difficulties with online translation services is poor accuracy for translating medical terminology (ie, Anatomical or condition-related terms). This qualitative study establishes a basic set of terms and phrases that could be used for the future development of quick reference linguistic guides. The guides can be used in visual communication or verbally for a proficient speaker. There are currently translation guides for 8 languages available from this qualitative study: http://sportmedschool.com/rosetta-stone-sports-medicine-translations/ Future studies could include testing the use of the guide in the field and collecting feedback from users and development of a smartphone application for practical field-side translation.

Informing Concussion Management in a High School Setting: Clarity of Physician Communication Plays a Role

Amanda M. Black, CAT(C), PhD,*,†,‡ Janet F. Aucoin, BKinH,*,†,§ and Carolyn A. Emery, PT, PhD*,†,‡,§,¶,‖

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

Objective: To examine barriers to and facilitators of appropriate concussion recognition and management in a high school setting from the perspective of students, teachers, coaches and school administrators.

Study Design: Qualitative study including focus groups and semi-structured interviews with key informants.

Subjects: Twenty-three students (9 males, 14 females), 24 teacher/teacher-coaches (11 males, 13 females), 5 female community coaches and 4 key informants (2 female principals, 1 female athletic director, 1 male sports medicine teacher) from Calgary and surrounding areas.

Observation Technique: We conducted 3 focus groups with students, 3 focus groups with teachers and teacher-coaches, 1 focus group with community coaches working in schools and interviews with 4 key informants. The interview guide focused on barriers to and facilitators of specific concussion management behaviours and was informed by the Theoretical Domains Framework.

Outcome Measures: Using thematic analysis, we explored key domains (ie, knowledge, social/professional role, beliefs about capabilities, beliefs about consequences, reinforcement, intentions, goals, memory, attention and decision process, environmental context, social influences, emotion, behavioural regulation) from the Theoretical Domains Framework associated with concussion recognition and management behaviours.

Results: Participant stakeholders collectively described over 15 behaviours as important for appropriate concussion management. Key barriers and facilitators related to knowledge, social or professional role, beliefs about capabilities, beliefs about consequences and environmental context were identified across participant groups. Some specific barriers identified included miscommunication or lack of communication between the parent or student and the teacher regarding instructions from the physician related to stage-appropriate school accommodations, uncertainty regarding appropriate accommodations and removal from play due to inexperience, and a belief that students still recovering from concussion should not be in the classroom until they are better.

Conclusions: Ensuring high school students receive appropriate evidence-informed care following concussion and have an appropriate transition through return to learn and school steps is a complex process that involves multiple stakeholders working together to ensure appropriate steps are taken. Written communication from the physician regarding a student's stage of recovery and recommended accommodations may help improve the process through consistent information shared with the student, parents, teachers/coach.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding from the Canadian Athletic Therapy Association, the National Football League Scientific Advisory Board, Canadian Institutes of Health Research, Alberta Innovates, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation. We would like to acknowledge the Calgary Board of Education, the Calgary Catholic School District, and all school administrators, teachers, coaches, and students involved for their time and support in completing this project.

Sensitivity and Specificity of X-Ray for Anterior Cruciate Ligament Injury

Neil Dilworth, MB, BAO, BCh, MScCH HPTE,* Nikrooz Farsad, MD,† Yiqiao Wang, MD,* and Duong Nguyen, MD, MSc (ClinEpi)‡

Affiliations: *University of Toronto, Toronto, ON, Canada; †University of Calgary, Calgary, AB, Canada; and ‡McMaster University, Hamilton, ON, Canada.

Objective: To determine available sensitivity and specificity data on radiographic signs for Anterior Cruciate Ligament injury in the literature.

Data Sources: Three databases (MEDLINE, EMBASE, and PubMed) were searched for studies with the Mesh terms (“X-Ray sign” or “radiograph sign”) and (“Anterior Cruciate Ligament tear” or “Anterior Cruciate Ligament rupture” or “ACL tear “or “ACL rupture”). Two reviewers, using inclusion and exclusion criteria conducted a title, abstract, and full-text review of eligible studies for x-ray signs of ACL rupture as well as related sensitivity and specificity data.

Main Results: One hundred sixty-seven articles met initial inclusion criteria. Ten radiographic signs associated with ACL injury were found: Segond fracture, arcuate fracture, avulsion of the tibial insertion site, avulsion of the femoral origin, fracture of the posterior aspect of the lateral tibial plateau, deep lateral femoral notch sign, radiographic anterior drawer sign, cupola sign, narrowed notch and peaking of the tibial spine, and haemarthrosis. The majority of studies regarding sensitivity and specificity focused on MRI findings. A single study was found with a sample size of 124, describing the sensitivity and specificity of the deep lateral femoral notch sign on radiograph to be 3.2% and 100% respectively.

Conclusion: Studies on both sensitivity and specificity of radiographic signs for anterior cruciate ligament injury are limited and have a relatively low sample size. Future studies of greater sample size and of various signs are needed to understand the importance of radiographic signs in relation to ACL tears.

On the Road to Prevention of Early Osteoarthritis: Development of an Exercise Intervention

Anu M. Räisänen, PT, PhD,* Jackie L. Whittaker, PT, PhD,*,†,‡,§ Clodagh M. Toomey, PT, PhD,* Kati Pasanen, PT, PhD,*,§,¶,‖ and Carolyn A. Emery, PT, PhD*,§,¶,**

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; ‡Arthritis Research Canada, Richmond, BC, Canada; §McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada; ¶Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; ‖Tampere Research Center of Sports Medicine, UKK Institute for Health Promotion Research, Tampere, Finland; and **Department of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: To develop a group-based exercise intervention aimed to prevent or delay the onset of post-traumatic knee osteoarthritis.

Study Design: A three-step intervention development process: (1) Applying clinical experience, previous research and exercise training principles; (2) Consulting experts; (3) Intervention testing.

Subjects: Experts (n = 9) in rehabilitation, return-to-play after knee injury, osteoarthritis prevention or treatment; young adults (n = 7) with a knee injury history.

Observation Technique: First, information gathered through a literature review was combined with the exercise training principles and investigators' clinical experience to create the SHRED Osteoarthritis exercise program. Secondly one-on-one interviews were conducted with osteoarthritis research, rehabilitation and return-to-sport experts. SHRED Osteoarthritis was revised based on the interview feedback. Lastly, a convenience sample of 7 young adults with history of knee injury tested the exercise program and provided feedback.

Outcome Measures: Experts perceptions on the SHRED Osteoarthritis program (eg, suggested changes, agreements with the existing program); knee-injured participants' experience with the SHRED Osteoarthritis program (eg, level of pain during the class, favorite exercises).

Results: In the first step it was established that SHRED Osteoarthritis would be delivered twice weekly as a physiotherapist-supervised 60-minute group exercise class. The program would include an 8-minute warm-up, 47-minute circuit of 8 exercise stations (squats, single-leg exercises, lunges, balance, jumping and landing, trunk, hamstrings, hip adductors) and 5-minute cool down. Each station would have 4 to 5 progressions. Based on feedback from experts, the balance station was removed and incorporated into the warm-up and 5 minutes of dynamic exercises following the circuit, the hip adductor station was converted to an adductor/abductor station and 25 of 29 exercise progressions were revised. Based on the intervention testing, the single-leg exercises, jumping and landing and trunk station were revised based on the feedback that these exercises did not progress as intended or provoked pain. Additionally, the adductor/abductor station was converted back to an adductor station as the combination with hip abductor exercises was perceived as too easy.

Conclusions: The SHRED Osteoarthritis exercise program will be used in a pilot study to determine the feasibility of the program and effects on self-reported symptoms and functional measures.

Acknowledgments: The authors would like to thank all the experts and knee-injured participants who took part in the development of the PrE-OA exercise program. The authors are grateful to Christina Le, PT, PhD Candidate and Linda Truong, PT, PhD Candidate for their support in the intervention development and for the opportunity to visit the Glen Sather Sports Medicine Clinic's FAST classes. This work is supported by the Canadian Institutes of Health Research SHRed Injuries Foundation Grant (C Emery PI). The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the IOC.

Sport Action Plans in Canada: Who Does What?

Chantelle Hanley, MSc* and Gwyneth de Vries, MD†

Affiliations: *Educator, Coaching Association of Canada, ParaNB, Fredericton, New Brunswick and Charlottetown, PE; and †Department of Clinical Neurosciences, Horizon Health Network, Fredericton, New Brunswick, Canada.

Objective: Canadian provinces and territories implement, via government departments, the Canada Sport Policy (2012) in the form of Action Plans. The Federal-Provincial/Territorial (F-P/T) Priorities for Collaborative Action (July 2017) and “Let's Get Moving” (2018) campaigns complement these efforts. The focus of this systematic review is to identify sport-related lifespan health, safety and well-being items in the provincial action plans and to identify gaps and interprovincial variability.

Data Sources: Online government websites, documents, policy statements, and consultants' reports for all 10 provinces and 3 territories of Canada were searched. Full texts were reviewed and Canada Sport Policy objectives were made into table format including provincial/territorial strategies and responsible departments.

Main Results: Every report, across every sector, government agency, age group, and special interest group in each province/territory agrees that the number one advantage of sport is good health. Every province/territory has a vision to achieve sport excellence and most (70%-80%) have methods to enhance sport capacity and interaction. Some plans combine organized sport with other physical activity and recreation. There is 100% commitment to support the Indigenous athlete and high commitment to female athletes and management of concussion. No province or territory has a solo sport or physical activity department. Only Prince Edward Island has sport as a division of a health/wellness department. Only Quebec links sport with an education ministry. Three provinces (Saskatchewan, Manitoba and Ontario) have sport named in a shared ministry (eg, with culture, tourism or parks).

Conclusions: Variability is seen among the provincial/territorial sport action plans. Governments do build sport participation and capacity but translation to practical issues (promoting lifetime sport, searching for funding, preventing or reporting physical/psychological injury) is not standardized. Interprovincial philosophical gaps/variability in governmental accountability may result in confusion and frustration among athletes, coaches, parents, health professionals, and administrators who aim to “do the right thing” in planning, reporting or research. Health professionals, not currently prominent in sport action plan development, might inform strategies to address complex issues (eg inevitable injuries and poor behaviour) while helping to promote activity/sport for improved health.

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