What the research says about concussion risk factors and prevention strategies for youth sports: A scoping review of six commonly played sports

Sport and Recreation Related Concussion in Children: National Concussion Surveillance System

INTRODUCTION

Concussions sustained during sports and recreational activities are a concern for young athletes. The purpose of this study was to estimate past 12-month sport- and recreation-related (SRR) traumatic brain injuries (TBIs) among a sample of children.

METHODS

Pilot data from the Centers for Disease Control and Prevention's National Concussion Surveillance System were analyzed. National Concussion Surveillance System utilized a cross-sectional random-digit-dial telephone survey using computer-assisted telephone interviewing to collect self/proxy-reported data from 2018 to 2019. Adults with children aged 5-17 in the household were asked about head injuries sustained by their children. Estimates were stratified by sociodemographic and injury circumstance characteristics. Data analysis occurred from April 2022 to July 2023.

RESULTS

Utilizing a tiered case definition developed by the Centers for Disease Control and Prevention, an estimated 6.9% (95% confidence interval [CI], 6.0%-7.8%) of the sample's 5-17-year-old children sustained at least one probable or possible SRR-TBI in the previous 12 months; 3.3% (95% CI, 2.7%-4.0%) of the children sustained at least one probable SRR-TBI. An estimated 63.6% (95% CI, 58.1%-69.0%) of all reported TBIs were attributed to SRR activities. Of the SRR-TBIs reported, 41.1% (95% CI, 33.0%-49.2%) were experienced while playing contact sports. Symptoms did not resolve for 8 or more days or had not resolved at the time of the interview for 18.1% (95% CI, 13.0%-23.1%) of the children's most recent SRR-TBI.

CONCLUSIONS

Many proxy-reported TBIs among children aged 5-17 years were due to sports and recreational activities. Athletic trainers and healthcare providers can play a role in the prevention, identification, and management of SRR-TBIs in their respective environments.

Sports Related Concussion

Sports-related concussions (SRC) have been a topic of interest for decades and are a prevalent risk of sports participation. The definition of SRC continues to evolve but includes a plausible mechanism and associated symptoms of injury. Rates of concussion vary among sports, and many sports have adopted rule changes to limit this risk for its athletes. There has been a considerable effort to prevent the occurrence of SRC, as well as a focus on safe return to learn and sport alike. There is growing concern about the ramifications of concussions, which will continue to warrant further investigation.

Neighborhood Disadvantage and Clinical Outcome Following Concussion in Adolescents

Whether social determinants of health are associated with clinical outcome following concussion among adolescents is not well established. The present study examined whether neighborhood-level determinants are associated with clinical recovery time following concussion in adolescents. Participants included adolescent student athletes (n = 130; mean age = 16.6, standard deviation = 1.2; 60.8% boys, 39.2% girls) who attended one of nine selected high schools in Maine, USA. The Area of Deprivation Index (ADI), an indicator of neighborhood disadvantage was used to group high schools as either high or low in neighborhood disadvantage. Athletic trainers entered injury and recovery dates into an online surveillance application between September 2014 and January 2020. Chi-squared analyses and Kaplan-Meier survival analyses were used to compare the groups on two clinical outcomes: days to return to school and days to return to sports. Results of chi-squared tests did not reveal between-group differences in return to school at 21 or 28 days. However, groups differed in the percentage of adolescents who had returned to sports by 21 days (greater neighborhood disadvantage, 62.5%, lesser neighborhood disadvantage 82.0%, χ2 = 4.96, p = 0.03, odds ratio [OR] = 2.73, 95% confidence interval [CI], 1.11-6.74) and 28 days (greater neighborhood disadvantage, 78.6%, lesser neighborhood disadvantage 94.0%, χ2 = 5.18, p = 0.02, OR = 4.27, 95% CI, 1.13-16.16) following concussion. A larger proportion of adolescents attending schools located in areas of greater neighborhood disadvantage took more than 21 and 28 days to return to sports. These results indicate an association between a multi-faceted proxy indicator of neighborhood disadvantage and clinical outcome following concussion. Further research is needed to better characterize factors underlying group differences in time to return to sports and the interactions between neighborhood disadvantage and other correlates of clinical recovery following concussion.

Neurocognitive Test Performance and Concussion-Like Symptom Reporting Among Adolescent Athletes With Self-Reported Autism on Preseason Assessments

OBJECTIVE

To examine baseline neurocognitive functioning and symptom reporting among adolescents with self-reported autism.

METHOD

Participants in this cross-sectional, observational study were 60,751 adolescents who completed preseason testing. There were 425 students (0.7%) who self-reported an autism spectrum disorder (ASD) diagnosis. Cognitive functioning was measured by Immediate Post-Concussion Assessment and Cognitive Testing and symptom ratings were obtained from the Post-Concussion Symptom Scale.

RESULTS

Groups differed significantly across all neurocognitive composites (p values <.002); effect size magnitudes for most differences were small, though among boys a noteworthy difference on visual memory and among girls differences on verbal memory and visual motor speed composites were noted. Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 symptoms at a greater rate. Some examples of symptoms that were endorsed at a higher rate among adolescents with self-reported autism were sensitivity to noise (girls: odds ratio, OR = 4.38; boys: OR = 4.99), numbness or tingling (girls: OR = 3.67; boys: OR = 3.25), difficulty remembering (girls: OR = 2.01; boys: OR = 2.49), difficulty concentrating (girls: OR = 1.82; boys: OR = 2.40), sensitivity to light (girls: OR = 1.82; boys: OR = 1.76), sadness (girls: OR = 1.72; boys: OR = 2.56), nervousness (girls: OR = 1.80; boys: OR = 2.27), and feeling more emotional (girls: OR = 1.79; boys: OR = 2.84).

CONCLUSION

Students with self-reported autism participating in organized sports likely experience a low degree of functional impairment, on average. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery.

The Relationship Between Neck Strength and Sports-Related Concussion in Team Sports: A Systematic Review With Meta-analysis

OBJECTIVE: We aimed to quantify the relationship between neck strength and sports-related concussion (SRC) for athletes participating in team sports. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: PubMed, PsycINFO, MEDLINE, CINAHL, CENTRAL, and Scopus were searched on March 17, 2022, and updated on April 18, 2023. STUDY SELECTION CRITERIA: Team sports where an opponent invades the player's territory (eg, football, rugby, basketball) that reported at least 1 measure of neck strength, and 1 measure of SRC incidence, using cohort, case-control, or cross-sectional study designs. The Newcastle-Ottawa scale was used to assess risk of bias; certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. DATA SYNTHESIS: Studies were summarized qualitatively and quantitatively. To understand the relationship between neck strength and future SRC incidence, random-effects meta-analysis was conducted on prospective longitudinal studies. RESULTS: From a total of 1445 search results, eight studies including 7625 participants met the inclusion criteria. Five studies reported a relationship between greater neck strength or motor control and reduced concussion incidence. Pooled results from 4 studies indicated small (r = 0.08-0.14) nonsignificant effects with substantial heterogeneity (I2>90%). The considerable heterogeneity is likely a result of synthesized studies with vastly different sample characteristics, including participant age, playing level, and sports. CONCLUSIONS: There was very low-certainty evidence suggesting a small, nonsignificant relationship between greater neck strength and a lower risk of sustaining a SRC. J Orthop Sports Phys Ther 2023;53(10):1-9. Epub: 10 July 2023. doi:10.2519/jospt.2023.11727.

Social Determinants of Health and Health Equity in the Diagnosis and Management of Pediatric Mild Traumatic Brain Injury: A Content Analysis of Research Underlying Clinical Guidelines

We conducted a content analysis of the literature underlying the Centers for Disease Control and Prevention (CDC) Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (i.e., the "Guideline") to determine the extent to which social determinants of health (SDoH) were examined or addressed. The systematic review forming the basis for the Guideline included 37 studies addressing diagnosis, prognosis, and treatment/rehabilitation. We examined those studies to identify SDoH domains derived from the U.S. Department of Health and Human Services' Healthy People 2020 and 2030 websites. No study explicitly mentioned "social determinants of health," by name, and few studies addressed SDoH domains as a primary focus (ranging from 0% to 27% of studies across SDoH domains). The most frequently represented SDoH domains, described in an inferential or a descriptive manner, were Education Access and Quality (29.7% of studies), Social and Community Context (27.0% of studies), and Economic Stability (21.6% of studies). Health Care Access (13.5% of studies) was less well represented and no studies (0%) examined Neighborhood and Built Environment. In terms of the CDC clinical questions, SDoH were only examined as predictors of outcome (prognosis) and no studies examined SDoH in relation to diagnosis or treatment/rehabilitation. The Guideline includes some commentary on health literacy and socioeconomic status. Overall, social determinants of health are largely unrepresented as important or meaningful variables influencing the Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, or in the studies that informed the Guideline.

Multinomial Estimations of Predictive Risk Factors for Traumatic Brain Injuries

Introduction Traumatic brain injuries (TBIs) affect millions of patients each year, with more than 220,000 hospitalizations in 2019 and 64,000 deaths in 2020 alone. TBIs span a plethora of injuries including cerebral contusions and lacerations, axonal injuries, optic pathway disruptions, and skull fractures. Previous research has established that characteristics such as sex, mechanism of injury (MOI), and blood-thinning agents have some causal connections to a variety of cranial traumas. Methods This paper sought to analyze aggravating risk factors for various TBIs in the New York City borough of Staten Island. Data on eight predictive risk variables were collected at a level 1 trauma center from January 1, 2022, to December 31, 2022: MOI, seizure history, anticoagulant/antiplatelet therapy, alcoholism, age, biological sex, tested alcohol level, and body mass index (BMI). A multinomial logistic regression was estimated to generate risk ratios (RRs), and chi-squared tests were carried out to determine univariate associations. Results It was found that blood thinner use and sex were both significant predictors of various types of TBIs. Additionally, those not tested for alcohol, including pediatric patients, were less likely to suffer most forms of TBI, while BMI had a negligible relationship with any TBI class. The use of blood-thinning agents put patients at an increased risk of concussions (relative risk ratio [RRR]: 1.82; 95% confidence interval [CI]: 1.10-3.02) and undiagnosed intracranial injuries (RRR: 1.90; 95% CI: 1.08-3.34). Men were at higher risk of multiple cranial injuries than women (RRR: 3.62; 95% CI: 1.38-9.48), as well as physical traumas such as brain lacerations and hemorrhages (RRR: 2.81, 95% CI: 1.28-6.18). BMI was weakly correlated with undiagnosed cranial injuries (RRR: 1.04; 95% CI: 1.00-1.08) and slightly uncorrelated with physical traumas (RRR: 0.94; 95% CI: 0.88-1.00). Those not tested for alcohol were at far less risk of multiple TBIs (RRR: 0.08; 95% CI: 0.01-0.66), concussions (RRR: 0.27; 95% CI: 0.11-0.71), and physical brain traumas (RRR: 0.33; 95% CI: 0.13-0.84). No parameter exhibited any statistical significance with skull fractures. Conclusion Particular risk factors for TBIs include biological sex and blood thinner use. Injury prevention efforts should be based on the category of TBI, with a particular focus on blood thinner users becoming concussive post-trauma. Attention should also be paid to men who engage in risky behavior such as binge drinking and crime sustaining more than one brain trauma or isolated brain bleeds. Therefore, improved hospital outreach for fall precautions in nursing homes and targeted interventions for at-risk men are vital for future projects.

Head and Neck Characteristics as Risk Factors For and Protective Factors Against Mild Traumatic Brain Injury in Military and Sporting Populations: A Systematic Review

BACKGROUND

Investigators have proposed that various physical head and neck characteristics, such as neck strength and head and neck size, are associated with protection from mild traumatic brain injury (mTBI/concussion).

OBJECTIVES

To systematically review the literature and investigate potential relationships between physical head and neck characteristics and mTBI risk in athletic and military populations.

METHODS

A comprehensive search of seven databases was conducted: MEDLINE, EMBASE, CINAHL, Scopus, SPORTDiscus, Cochrane Library, and Web of Science. Potential studies were systematically screened and reviewed. Studies on military and athletic cohorts were included if they assessed the relationship between physical head-neck characteristics and mTBI risk or proxy risk measures such as head impact kinematics.

RESULTS

The systematic search yielded a total of 11,723 original records. From these, 22 studies met our inclusion criteria (10 longitudinal, 12 cross-sectional). Relevant to our PECO (Population, Exposure, Comparator, and Outcomes) question, exposures included mTBI incidence and head impact kinematics (acceleration, velocity, displacement) for impacts during sport play and training and in controlled laboratory conditions. Outcome characteristics included head and neck size (circumference, mass, length, ratios between these measures), neck strength and endurance, and rate of force development of neck muscles.

DISCUSSION

We found mixed evidence for head and neck characteristics acting as risk factors for and protective factors against mTBI and increased susceptibility to head impacts. Head-neck strength and size variables were at times associated with protection against mTBI incidence and reduced impact kinematics (14/22 studies found one or more head-neck variable to be associated with protection); however, some studies did not find these relationships (8/22 studies found no significant associations or relationships). Interestingly, two studies found stronger and larger athletes were more at risk of sustaining high impacts during sport. Strength and size metrics may have some predictive power, but impact mitigation seems to be influenced by many other variables, such as behaviour, sex, and impact anticipation. A meta-analysis could not be performed due to heterogeneity in study design and reporting.

CONCLUSION

There is mixed evidence in the literature for the protective capacity of head and neck characteristics. We suggest field-based mTBI research in the future should include more dynamic anthropometric metrics, such as neck stiffness and response to perturbation. In addition, laboratory-based mTBI studies should aim to standardise design and reporting to help further uncover these complicated relationships.

Attention-Deficit/Hyperactivity Disorder and Outcome from Concussion: Examining Duration of Active Rehabilitation and Clinical Recovery

AIMS

The objective of this study was to compare recovery time and duration of active rehabilitation following concussion between adolescents with and without attention-deficit/hyperactivity disorder (ADHD).

METHODS

A retrospective cohort study was conducted among adolescents presenting to a specialty concussion clinic. One-quarter of the eligible episodes of care were selected. The final sample included 540 adolescents (ages 13-17 years, median age 15 years; 49.8% girls), of which 65 (12.0%) had a pre-injury diagnosis of ADHD. Days to recovery and days of active rehabilitation were examined.

RESULTS

ADHD was not associated with recovery time (ADHD: median = 49 days, IQR = 25-77; No ADHD: median = 47 days, IQR = 29-85) in univariate (Z = -0.45; p = 0.65) or multivariable analyses (Hazard Ratio: 1.17 (0.85-1.61); χ²(1) = 0.95; p = 0.33). The duration of active rehabilitation services received did not differ between youth with ADHD (median = 38.5 days, IQR = 27.5-54.5) and without ADHD (median = 37.5 days, IQR = 18.5-66) in univariate (Z = -0.19; p = 0.85) or multivariable analyses (Hazard Ratio: 1.04 (0.67-1.63); χ²(1) = 0.03; p = 0.85).

CONCLUSIONS

Our findings support accumulating evidence that ADHD, in and of itself, is not a risk factor for longer recovery or worse outcomes following pediatric concussion.

Concussion Among Children in the United States General Population: Incidence and Risk Factors

The objective of this study was to examine the incidence of concussion and risk factors for sustaining concussion among children from the United States general population. This prospective cohort study used data from the Adolescent Brain Cognitive Development (ABCD) Study^®. Children were recruited from schools across the US, sampled to reflect the sociodemographic variation of the US population. The current sample includes 11,013 children aged 9 to 10 years old (47.6% girls; 65.5% White) who were prospectively followed for an average of 1 year (mean = 367.9 days, SD = 40.8, range 249–601). The primary outcome was caregiver-reported concussion during a 1 year follow-up period. Logistic regression was used to determine which potential clinical, health history, and behavioral characteristics (assessed at baseline) were prospectively associated with concussion. In the 1 year follow-up period between ages 10 and 11, 1 in 100 children (n = 123, 1.1%) sustained a concussion. In univariate models, three baseline predictors (ADHD, prior concussion, and accident proneness) were significantly associated with sustaining a concussion. In a multivariate model, controlling for all other predictors, only prior concussion remained significantly associated with the occurrence of a concussion during the observation period (Odds Ratio = 5.49, 95% CI: 3.40–8.87). The most robust and only independent prospective predictor of sustaining a concussion was history of a prior concussion. History of concussion is associated with 5.5 times greater odds of sustaining concussion between ages 10 and 11 among children from the general US population.

Factors associated with concussion symptom knowledge and attitudes towards concussion care-seeking among parents of children aged 5-10 years

BACKGROUND

Understanding parents' concussion-related knowledge and attitudes will contribute to the development of strategies that aim to improve concussion prevention and sport safety for elementary school children. This study investigated the association between parent- and child-related factors and concussion symptom knowledge and care-seeking attitudes among parents of elementary school children (aged 5-10 years).

METHODS

Four hundred parents of elementary school children completed an online questionnaire capturing parental and child characteristics; concussion symptom knowledge (25 items, range = 0-50; higher = better knowledge); and concussion care-seeking attitudes (five 7-point scale items, range = 5-35; higher = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher score levels. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) excluding 1.00 were deemed statistically significant.

RESULTS

Select parent and child characteristics were associated with higher score levels for both outcomes. For example, odds of better knowledge level in parents were higher with increased age (10-year increase aOR = 1.59; 95% CI = 1.10-2.28), among females (aOR = 3.90; 95% CI = 2.27-6.70), and among white/non-Hispanics (aOR = 1.79; 95%CI = 1.07-2.99). Odds of more positive concussion care-seeking attitude levels were higher among parents with a college degree (aOR = 1.98; 95%CI = 1.09-3.60). Child sports participation was not associated with higher score levels for either outcome.

CONCLUSIONS

Certain elementary school parent characteristics were associated with parents' concussion symptom knowledge and care-seeking attitudes. While the findings suggest providing parents with culturally and demographically relevant concussion education might be helpful, they also emphasize the importance of ensuring education/prevention regardless of their children's sports participation. Practical Applications: Pediatric healthcare providers and elementary schools offer an optimal community-centered location to reach parents with this information within various communities.

Physical Conditioning Strategies for the Prevention of Concussion in Sport: a Scoping Review

BACKGROUND

Concussion in sports has received a great deal of media attention and may result in short and longer-lasting symptoms, especially in adolescents. Although significant strides have been made in the identification and management of concussion, less is known about the primary prevention of this condition. The aims of this scoping review are to (1) summarize the current research of physical conditioning strategies to reduce or prevent concussion incidence in individuals participating in sport, especially adolescents, and (2) to identify gaps in the knowledge base. Our research question was what is known from the existing literature about physical preparation strategies to reduce or prevent concussion in adult and adolescent sports?

METHODS

Three literature searches were conducted by information officers at two universities at six-month intervals, using five electronic databases (PubMed; WorldCat.org ; Mendeley; EBSCOHost and Ovid MEDLINE). To increase the search range, subject experts were consulted and articles and reference lists were hand searched. A scoping review methodology identified eligible studies that analyzed physical preparation techniques on modifiable physical risk factors in athletes to reduce the incidence of concussion. The PRISMA-ScR checklist guided the reporting of the findings.

RESULTS

A total of 1414 possible articles were identified, after duplicates removed, and articles analyzed against the inclusion and exclusion criteria, only 9 articles qualified for analysis. Two articles were found from studying reference lists. Thus, a total of 11 articles were included in the final evaluation for the purposes of this study. Data are reported from mostly adolescent subjects participating in nine different sports from three countries. Findings are presented with specific reference to previously recognized modifiable risk factors of concussion which include neck strength, neck size, cervical stiffness, type of sport, and pre-activity exercises.

CONCLUSIONS

There is limited research examining the physical preparation of athletes, especially in adolescents, to reduce or prevent concussion, and conflicting evidence in the few small sample studies that were identified. This scoping review identifies the research gap for a potentially vital modifiable risk factor, notably in the physical preparation of children and adolescents to reduce or prevent sports-related concussion.

Head Impact Exposures Among Youth Tackle and Flag American Football Athletes

Background:

Promoted as a safer alternative to tackle football, there has been an increase in flag football participation in recent years. However, examinations of head impact exposure in flag football as compared with tackle football are currently limited.

Hypothesis:

Tackle football athletes will have a greater number and magnitude of head impacts compared with flag football athletes.

Study Design:

Cohort study.

Level of Evidence:

Level 4.

Methods:

Using mouthguard sensors, this observational, prospective cohort study captured data on the number and magnitude of head impacts among 524 male tackle and flag football athletes (6-14 years old) over the course of a single football season. Estimates of interest based on regression models used Bayesian methods to estimate differences between tackle and flag athletes.

Results:

There were 186,239 head impacts recorded during the study. Tackle football athletes sustained 14.67 (95% CI 9.75-21.95) times more head impacts during an athletic exposure (game or practice) compared with flag football athletes. Magnitude of impact for the 50th and 95th percentile was 18.15g (17.95-18.34) and 52.55g (51.06-54.09) for a tackle football athlete and 16.84g (15.57-18.21) and 33.51g (28.23-39.08) for a flag football athlete, respectively. A tackle football athlete sustained 23.00 (13.59-39.55) times more high-magnitude impacts (≥40g) per athletic exposure compared with a flag football athlete.

Conclusion:

This study demonstrates that youth athletes who play tackle football are more likely to experience a greater number of head impacts and are at a markedly increased risk for high-magnitude impacts compared with flag football athletes.

Clinical Relevance:

These results suggest that flag football has fewer head impact exposures, which potentially minimizes concussion risk, making it a safer alternative for 6- to 14-year-old youth football athletes.

A Qualitative Study of Youth Football Coaches' Perception of Concussion Safety in American Youth Football and Their Experiences With Implementing Tackling Interventions

Due in part to concern about the potential long-term effects of concussion and repetitive head injuries in football, some programs have implemented tackling interventions. This paper explores youth football coaches' perception of football safety and their experiences implementing these interventions aimed at athlete safety. Using a qualitative approach, coaches were interviewed by means of a semi-structured protocol that covered: (a) demographics; (b) background and experiences; (c) personal relevance risks, safety, and benefits of youth football; (d) experiences with tackling technique; (e) experiences with mouth guard sensors; and (f) opinions on disseminating information on football safety. Most coaches felt that learning tackling at a young age helped prepare them for their playing later in life and believed that youth should begin playing tackle football at a young age. Coaches were mixed regarding their concerns about the risk for concussion and subconcussive head impacts. Still, most were receptive to changes in rules and policies aimed at making football safer. Findings from this study demonstrate that youth football coaches are important stakeholders to consider when implementing changes to youth football. Understanding coach perceptions and experiences may inform future efforts aimed to educate coaches on rules and policies to make the game safer for youth athletes.

Developing a Comprehensive, Interdisciplinary Concussion Program

There has been a growing trend of local and national coverage of and interest in concussion injuries over the past 2 decades. Increasing public concern over potential catastrophic and unknown long-term effects of sports-related concussion injuries has led to an acknowledgment of the strong public health need for addressing all concussion injuries, regardless of mechanism of injury. In efforts to address this need for concussion prevention and management, both in sports and nonsports, The University of Kansas Health System initiated the interdisciplinary Center for Concussion Management program in 2012. The program was created as a virtual clinic concept and includes voluntary participation from various providers across the institution, limited budget, and space obstacles. Since its inception, the program has continued to operate as its initial design of a multidisciplinary team model outside the sole ownership of 1 department, and has expanded to include education and outreach to local and regional schools and groups.

Concussion-Prevention Strategies Used in National Collegiate Athletic Association Divisions I and II Women's Soccer

CONTEXT

Whereas much attention has been paid to identifying mechanisms for decreasing concussion rates in women's soccer players, which strategies are currently being used is unknown. In addition, athletic trainers' (ATs') knowledge and beliefs about the efficacy of concussion-prevention practices have not been studied.

OBJECTIVES

To evaluate the concussion-prevention strategies being used in National Collegiate Athletic Association Division I and Division II women's soccer and identify the beliefs of certified ATs regarding mechanisms for preventing concussion.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 223 women's soccer team ATs employed at Division I or II universities.

MAIN OUTCOME MEASURE(S)

A survey instrument of structured questions and open-ended, follow-up questions was developed to identify the use of cervical-strengthening programs, headgear, and other techniques for preventing concussion. Questions also addressed ATs' beliefs regarding the effectiveness of cervical strengthening, headgear, and mouthguards in concussion prevention. Data were collected via questionnaire in Qualtrics survey software. Descriptive statistics of frequencies and percentages were calculated for close-ended questions. Open-ended questions were evaluated for common themes, which were then reported by response frequency.

RESULTS

Cervical strengthening or stability for concussion prevention was reported by 38 (17.12%) respondents; 153 (69.86%) ATs believed that cervical strengthening would aid in concussion prevention. Seventy-eight (35.49%) reported that their players wore headgear. Nineteen (8.76%) believed that soccer headgear prevented concussions; 45 (20.74%) believed that mouthguards prevented concussions. Education in proper soccer technique was reported by 151 (69.59%) respondents. Fourteen (0.06%) respondents cited nutritional strategies for concussion prevention.

CONCLUSIONS

Although ATs believed that cervical strengthening could help prevent concussions, few had implemented this strategy. However, the ATs whose teams used headgear outnumbered those who believed that headgear was an effective prevention strategy. Based on our findings, we saw a disconnect among the current use of concussion-prevention strategies, ATs' beliefs, and the available evidence.

Should you let your child play football? What about soccer or hockey?

College students (n = 120) answered 18 yes-no questions that varied the child's gender (male, female), grade (grade school, high school, college), and sport (football, soccer, hockey). The format of the 18 yes or no questions was "If you had a child in (grade school, high school, college) would you let (him, her) play (football, soccer, hockey)"? Similar to a previous study, a large percentage (78.8%) of the respondents answered yes to the questions about football, indicating that they would permit their children to play football despite the risk of concussion (96% yes for male children, 67% yes for female children). Although the number of respondents who would allow their male child to play soccer (98% for male children, 99% for female children) or hockey (92% for male children, 89% for female children) was similar to the percentage of respondents that would allow their male child to play football, significantly more respondents would allow their female child to play soccer or hockey than football. This result is potentially problematic because soccer and hockey have high rates of concussion, especially for females, which suggests that the respondents may have been unaware of this fact.

Youth and high school sports coaches' experience with and attitudes about concussion and access to athletic trainers by sport type and age of athlete coached

INTRODUCTION

Concussions are a commonly reported injury in youth and high school sports and much of the responsibility related to concussion identification and response for young athletes is allocated to sports coaches. This paper presents findings on concussion-related education, access to resources, experiences, and attitudes among a large number of youth and high school sports coaches across a variety of sports nationwide.

METHODOLOGY

Data were collected among coaches who completed the Centers for Disease Control and Prevention's (CDC) HEADS UP online concussion training pre-test between November 2016 and November 2017. Coaches' concussion-related education, access to resources, experiences, and attitudes were compared by age of athlete coached and level of contact of sport. Medium and large effect sizes were considered of practical significance for interpretation.

RESULTS

During the study period, 187,801 youth sports or high school sports coaches completed the CDC HEADS UP online training and corresponding pre-test. Access to previous concussion training significantly varied among respondents by age of athlete coached. For example, 27.4% of coaches of athletes aged 5 and younger had taken previous training compared to 72.9% of coaches of athletes aged 14-18. About one-quarter (27.4%) of all coaches reported ever having had to pull an athlete out of a game because of a possible concussion and 19.5% reported access to an athletic trainer at all games and practices. These variables differed significantly among coaches by age of athletes coached; coaches of older athletes were more likely to report access to an athletic trainer and having had to pull an athlete out of a game compared to coaches of younger athletes. No statistical differences by level of contact were considered to be of practical significance based on effect size.

CONCLUSION

Most coaches in this study report having access to education and hold attitudes consistent with best practices about concussion safety; however, overall access to concussion-related resources is limited. While differences in access to concussion-related education, experience, resources, and attitudes among coaches of varying levels of contact were small, medium to large variations were identified by age of athlete coached. Practical applications: Coaches bear an important part of the responsibility to prevent, identify, and manage concussions in young athletes. Tailored educational efforts may assist coaches of young athletes with recognition of concussion signs and symptoms and with feeling comfortable deciding whether an athlete needs to be evaluated for a possible concussion.