Epidemiology of concussions among United States high school athletes in 20 sports
Marar M., McIlvain, NM., Fields SK., Comstock JD., DR Comstock, American Journal of Sports Medicine. January 2012: ahead of print
Concussions are a major health concern across many different sports. However, much of the research focuses on football despite evidence that women are at greater risk for concussions. Few authors have focused on comparing concussion rates within gender across sports. Therefore, the purpose of this study was to update and expand upon prior epidemiology studies by studying concussions among high school athletes across 20 sports. Information was analyzed from National High School Sports-Related Injury Surveillance System, High School Reporting Information Online. As part of the injury surveillance system, certified athletic trainers from high schools around the country reported injuries and exposures (playing/practice time per athlete) for 20 sports. This investigation describes the details of concussion injury patterns by sport in terms of severity (i.e., days lost), mechanisms, activities, symptoms, and amount of time for symptoms resolution. During the 2008-2010 seasons 1,936 concussions were reported during 7,780,064 athlete exposures. The injury rate was higher in competition (67%) than practice (33% of concussions). The majority of concussions were reported from participation in football (47%) followed by girls’ soccer (8%), wrestling (6%), and then girls’ basketball (5.5%). Concussion rate (number of concussions/number of exposures) was highest in football followed by boys’ hockey, and boys’ lacrosse. In gender comparable sports (e.g., soccer, basketball, what else?), girls had higher concussion rates than boys. The most commonly reported signs and symptoms were headache (94%), followed by dizziness (76%), difficulty concentration (55%), and then confusion (45%). Most common mechanism of concussion were player-to-player contact (70%) followed by player-player surface contact (17%). Athletes most commonly returned to play within 1 to 3 weeks (55%). Twenty-two percent returned in less than 1 week and 2% returned in less than 1 day.
Concussion rates vary by sport, gender, and exposure type (practice or competition). An understanding of concussion rates, patterns of injury, and risk factors can lead to a more specific education program of preventative measures for athletic trainers, referees, coaches, parents, and athletes to reduce the risk of concussions within high schools. This could lead to better protective equipment and regulatory efforts. Though there are some innate differences among sports, there were some consistent concussion variables across sports as well. For example overall concussion rates were higher during contests than in practice (except in cheerleading). Methods of reducing risk of player-to-player contact during game situations may help decrease concussion rates. This could be done via rule changes or more vigilant control over the rules in place. This is why it is important for referees to receive concussion education. Also, in all gender comparable sports (e.g., soccer) girls had higher concussion rates. Girls’ may have a biomechanical disadvantage, where they do not have sufficient neck strength to control deceleration of the head that could lead to a contra-coup brain injury. This difference in concussion rate could also be attributed to the recent discovery that girls may inheritably be more honest thus incorporating a reporting bias into the study. In addition concussed high school athletes on average missed more than 1 week of sports activity, no matter what sport they were playing. The concussion rate reported in this study was 13% of all reported injuries, which is higher than the last reported studies 5.5% (reported in 1999), 7.5% (reported in 2004), and 8.9% (reported in 2007). This possible trend in increasing concussion rates could be due to the inclusion of boys’ lacrosse and boys’ ice hockey or an increased awareness about the risk of concussions. This study also included concussions that led to time lost less than a day. However, this is a bit alarming since this violates the consensus that no high school athlete suspected of a concussion should to return to play on the day of the injury. Is your primary focus on concussion education within only high- risk sports? Do you believe rule changes are necessary to decrease concussion rates?
Written by: Jane McDevitt MS, ATC, CSCS
Reviewed by: Jeffrey Driban
News Article of Interest:
Marar M, McIlvain NM, Fields SK, & Comstock RD (2012). Epidemiology of Concussions Among United States High School Athletes in 20 Sports. The American Journal of Sports Medicine PMID: 22287642
It is so hard to try and legislate injury out of a game let alone all games due to their varying dynamics. How many times have we heard coaches harping on football players to tackle with their heads up only to have them revert to using their head as a battering ram? Do we then eliminate heading in soccer altogether? The sheer speed and mass of hockey players today is a concussion recipe that when a player is checked into the boards, there is always some chance of brain trauma due impact, the boards, and the resultant rebound of the head. I do firmly believe that headshots should be eliminated in all forms of hockey and that equipment modifications must be made, especially with respect to elbow and shoulder pads. Altogether, it's going to happen in sport. To think that concussions can be 100% legislated away is folly. Yes some rules can be adjusted and made tougher, but I believe PREVENTION and EDUCATION is much more important than turning a sport on its head, no pun intended. We need to show our value by implementing neck strengthening exercises as to improve dynamic stability vs head trauma, especially in terms of soccer heading. If we consider Janda's upper crossed syndrome, which most people will present with, the athlete is already behind the 8 ball in terms of next strength and dynamic protection. This is where we need to start.
Mark, I agree with you. No matter what rules are in place there will always be a chance that a concussion could occur in a game or practice. Many of the concussions in the article were from player to player contact. This was in both male and female sports. In some women sports like lacrosse there is much less contact compared to men's lacrosse. Yet, there are still player to player contact concussions such as going for the same ball and running into each other. There is no rule that is going to change those instances. Like you had mentioned, it is the stricter reinforcement of rules in place and education that will help prevent concussions. For example, maybe if football players knew the repercussions of spearing they may be more apt to practice the head up tacking technique, that they should be utilizing during play. Implementing head and neck strengthening programs is another great way to prevent concussions especially for soccer athletes.
Both of you make good points. I think more neck strengthening would be beneficial but I will go one step further and suggest this trend towards bigger and faster athletes has gone a bit too far. More of the focus needs to be on muscle control and coordination and not so much on pure power and size. especially at such young ages.
The size of the athletes combines with the speed of the competitions doesn't leave much time for conscious control of body position and technique will revert to what is most ingrained. The magnitude of the forces that are often produced by these hits are rather large. Most every coach I have ever worked with from college down to flag does the best they can to teach the kids the appropriate form but the increase in the injury rates may be good evidence that the training is either not enough or not being given enough emphasis.
I also have to wonder if, in terms of the actual physics, how much neck strength would be enough to control the forces that injury causing hits produce? If any one who reads this is a math person or knows some one who is I would love to actually see the calculations, especially for football, hockey, rugby, and lacrosse.
And just as a note from my days as a player (2004 being my last game year playing high school ball) we knew the dangers of spearing. No one wanted to get hurt (even though we would joke about getting something minor to get out of practice but still play) but when that ball was snapped I had no room in my mind to think about form. There was way to much else to worry about. We just went out and did the best we could to do everything right. Im not sure more education on the dangers is going to reduce injury rates very much. It may help with truthful reporting though.
Jake, I think that you make some good points. Especially where football is concerned, I believe fatigue is a huge contributor to head injuries. I don't know what the actual weight of a football helmet is, but we know that it's not insignificant. Wear that thing for a full game, on top of having to play both ways (at least at smaller schools), and these kids are behind the eight ball, in a sense.
To your other point, I disagree on your statement about more education. It's not about reducing injury rates through education, necessarily, it's about making the fact known that we are doing everything that can be done to reduce injury rates, and this is why we are doing the program that we are doing. By getting administrators, parents, coaches and players on board we can potentially decrease injury rates and increase the value of the services that we provide.
You can't tell me that if you and the coach sat down at a high school soccer boosters meeting, and you spoke for 25 minutes about soccer heading, concussion incidence, foundational weaknesses in the neck and thoracic region and how to address it they wouldn't listen.
I do not know what education statement you are referring to, however, I do believe education is one of the only ways we can reduce injury rates. I agree that education needs to reach not only the coaches and players, but referees, parents, and administrators. I think many people do not even know the basics about a concussion such as mechanisms, signs and symptoms, and normal duration of a brain injury. I believe awareness needs to be increased as well as preventative measures such as strength conditioning programs.
next to the last line of Jake's post. "Im not sure more education on the dangers is going to reduce injury rates very much."
Let me clarify, because my earlier comments are a bit muddled . Education is hugely important. But education alone won't be enough to decrease injury rates. Education needs to be coupled with ACTION to decrease injury rates. You can listen to a lecture all about preventing shoulder injuries in throwers, but not implementing those ideas, as good as they are, does nothing to decrease injury. Presenting education with action is where all the difference will be made.
I think that the institutions, athletes, coaches and referees have increased their knowledge about concussions over the years. At my university I know that the athletic trainers have a presentation that they do for all the sports on concussion prevention,the signs and symptoms and when you should seek help.