Concussion remains a common injury among sports participants. Implementing risk-reduction strategies for sport-related concussion (SRC) should be a priority of medical professionals involved in the care of athletes. Over the past few decades, a multifaceted approach to reducing SRC risk has been developed. Protective equipment, rule and policy change/enforcement, educational programs, behavioral modifications, legislation, physiologic modifications, and sport culture change are a few of the programs implemented to mitigate SRC risk. In this article, the authors critically review current SRC risk-reduction strategies and offer insight into future directions of injury prevention for SRC.
Key points
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Few prospective, randomized controlled trials evaluating sport-related concussion (SRC) prevention strategies exist.
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Many initiatives and recommendations pertaining to elite adult athletes have been inappropriately extrapolated to groups of different ages and skill levels, including youth and adolescent athletes.
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Rule and policy changes remain promising tactics to reduce risk of SRC, but more research assessing their effectiveness in a variety of contact/collision sports and athlete age groups is needed, as is research pertaining to enforcement of these rule and policy changes.
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Educational institutions and sport organizations play an integral role in reducing SRC risk by ensuring recruitment practices in Division I collegiate athletics do not jeopardize the physical and mental health of prospective middle school and high school student athletes.
Introduction
Concussion remains a common injury among participants in youth, adolescent, and adult sports. An estimated 283,000 children seek care in US emergency departments each year for sport- or recreation-related traumatic brain injury (TBI); contact sports account for approximately 45% of these visits. Although eliminating concussion in contact and collision sports is not a practical goal, implementing practices and strategies to reduce the risk of sport-related concussion (SRC) and their long-term sequalae should be a primary objective of sports organizations and their members. It is essential for medical professionals involved in the care of these athletes to support concussion reduction strategies.
Initial prevention efforts primarily focused on protective equipment and rule changes. However, over the past few decades, initiatives involving educational programs, legislation, physiologic and behavior modifications, teaching proper body checking and tackling technique, and changing culture in sport have collectively shown promise in mitigating risk of concussion in contact and collision sports.
The effectiveness of concussion prevention strategies in reducing concussion risk in sport has recently been assessed by several working groups using systematic reviews. , Emery and colleagues reviewed peer-reviewed full-text and abstracts of analytical study designs (including randomized controlled trials, quasi-experimental, cohort, case-control, cross-sectional, preexperimental, ecological) evaluating a concussion prevention intervention including human sport participants with concussions or head impacts. Schneider and colleagues reviewed prospective study design full-text articles limited to sport and recreation examining the preventative effect of equipment, training modifications, or educational programs on the incidence of concussions in comparison to a control group.
Overall, there are few prospective, randomized controlled trials (RCTs) that evaluate concussion prevention strategies. Many initiatives and recommendations have focused on studies involving elite adult athletes, and their results have been extrapolated contentiously to youth and adolescent sports. ,
The purpose of this article is to provide an update on the multifaceted approach to risk reduction of SRC in youth, adolescent, and adult sports. The focus will be on current evidence-based strategies and promising future directions that have yet to be rigorously studied.
Protective equipment
Helmets/Headgear
Significant morbidity and mortality in American football sparked the adoption of modern head protection. Mandatory helmet use was not instituted in American football until 1939 in the National Collegiate Athletic Association (NCAA) and 1943 in the National Football League. Even with required helmet use, serious head injuries including intracranial hemorrhages and skull fractures remained prevalent in American football throughout the mid-twentieth century. These troubling injuries prompted changes in the rules and coaching techniques. In 1969, the National Operating Committee on Standards for Athletic Equipment formed as a governing body to test and certify helmets and implemented the first football helmet safety standards in 1973. ,
American football
Because the current sports concussion management guidelines were developed and refined through a rigorous consensus process, , few studies regarding the effectiveness of helmets in reducing head injury during American football play have been published. Studies conducted before the Prague/Zurich concussion consensus conferences tended to underreport concussive injuries, reported only the most severe concussive injuries, and relied on coach and certified athletic trainer for diagnosis. , , Although newer helmet designs have the potential to reduce impact forces involving the crown of the helmet and the facemask, they are ineffective in mitigating the movement of the brain within the skull (“brain slosh”), resulting in suboptimal energy absorption for brain tissue protection.
One of the most referenced prospective cohort studies involving American football helmet design was performed by Collins and colleagues during the 2002 to 2004 seasons comparing concussion rates and recovery times for 2141 high school football players. Nearly half the sample wore newer helmet technology (Riddell Revolution), and the remainder used reconditioned traditional helmet designs from various manufacturers. Over the course of the study, the concussion rate of the Revolution helmet group was 5.3% compared with 7.6% in the traditional helmet group ( P <.03). However, the impact exposure for the affected players was not tracked, which limited the comparison conclusions. In addition, the study was limited by lack of randomization of helmets among study participants, mean chronologic age discrepancies among study groups, and variability in helmet age, as the Revolution helmets were brand new, whereas traditional helmets were reconditioned.
McGuine and colleagues performed a prospective cohort study of 2081 high school football players during the 2012 and 2013 seasons to determine whether the type of protective equipment and player characteristics affect the incidence of SRC. There were 211 SRCs sustained by 206 players (9% of included athletes), for an incidence of 1.6 SRCs per 1000 athletic exposures (AEs). No difference in incidence of SRC for players wearing Riddell, Schutt, or Zenith helmets was identified. In addition, helmet age and recondition status did not affect the incidence of SRC. Limitations of this study included lack of randomization of helmets among study participants and lack of impact exposure data to include in the analysis.
Rugby
Internationally, rugby is the most popular team collision sport. Headgear for rugby is made of soft polyethylene foam; current evidence is lacking regarding its effectiveness for reducing head impact forces or concussion incidence in rugby. , McIntosh and colleagues performed a 3-arm RCT involving 82 rugby union teams consisting of men younger than 13-, 15-, 18-, and 20-year age groups. There were 1493 participants in the control group (no headgear), 1128 participants who wore standard (10 mm thick) headgear, and 1474 participants who wore modified (16 mm thick) headgear. Participants were followed over 2 years. Compliance to random assignment was overall low, although in 46% of exposures, players wore standard headgear. No differences in the rates of head injury or concussion between controls and headgear arms was found following an intention-to-treat analysis. However, poor compliance with control or intervention group assignment limits interpretation of the study’s findings.
Ice hockey
Similar to American football, ice hockey protective headgear has undergone technological advances, beginning with leather and felt construction in the 1950s and the introduction of plastic shells and foam liners in the 1970s, which could absorb energy and provide a comfortable fit. In 1979, the National Hockey League (NHL) adopted head protection 11 years following a fatal head injury during NHL play. Despite the widespread use of helmets at both amateur and professional levels, brain injuries remain a serious concern.
Soccer
Until recently, no RCT had been performed involving protective headgear for soccer players. Quality of evidence historically was low, limited to retrospective surveys and laboratory studies. In 2019, McGuine and colleagues published a randomized controlled trial involving high school male and female soccer players performed during the 2016/17 and 2017/18 seasons. Schools were randomly assigned to be in headgear and no headgear (control) groups based on stratified randomization by school enrollment size. Individuals were allowed to choose which headgear model to wear for the season. There were 2766 participants, and 130 participants (5.3% women, 2.2% men) sustained SRCs. Neither the incidence of SRC nor the days lost from SRC were different between the groups for either men or women. Limitations of the study included potential selection bias, no video recording of concussion injury to document the head impacts or accelerometer data to record impact forces, and use of multiple headgear models in the headgear group.
Mouthguards
There are 3 main types of mouthguards: stock, boil-and-bite, and custom-fitted. Stock mouthguards are ready to wear, whereas boil-and-bite mouthguards must first be heated and then can be molded to the teeth while cooling. Custom mouthguards must be made by a dental professional and offer the best fit. In theory, mouthguards reduce concussion risk by dissipating force absorbed by the mandible as the mandibular condyle approaches the mandibular fossa of the temporal bone, partially absorbing force that otherwise would reach the brain.
There are no RCTs involving mouthguards and concussion prevention, given the questionable ethics of performing an RCT in collision sports where mouthguard use is mandated. Existing evidence is limited, and results have been inconclusive. Systematic reviews have cited small sample sizes, confounding factors including varying mouthguard thickness, inconsistent accounting for AEs, potential underreporting of injuries by athletic trainers, and self-report measurement bias. ,
Rule and policy changes/enforcement
Rule and policy changes in sport have the potential to reduce concussion risk and improve the health and safety of participants. In 2014, the Institute of Medicine’s Committee on Sports-Related Concussions in Youth acknowledged that although some evidence from youth ice hockey and soccer demonstrates that rule modification and enforcement of player safety and Fair Play policies contribute to a reduction in sports-related injuries, including concussion, more research is necessary to measure the effectiveness of rules in reducing concussion. In a 2017 systematic review of existing strategies to reduce the risk of concussion in sport, Emery and colleagues concluded that the most compelling evidence involves body checking policies in youth ice hockey, where not allowing body checking demonstrates a significant protective effect in reducing concussion risk. A call for further research investigating rule changes in other sports and age groups has been brought forward by international committees.
American Football
The kickoff return in American football, during which athletes run at high speeds toward each other over long distances, has historically been associated with a high concussion risk compared with other football plays. In 2016, the Ivy League introduced 2 key changes to its football kickoffs: (1) kickoffs were moved up from the 35-yard line to the 40, and (2) touchbacks were moved from the 20-yard line to the 25. The intent of these changes was to have more kickoffs land in the end zone, disincentivizing receivers from returning the kick and risking head injury from collisions with oncoming defenders. Wiebe and colleagues studied the effects of these rule changes on concussion rates in Ivy League football players during 5 seasons—3 preceding the rule change and 2 following the rule change (2013–15, 2016–17). The mean annual concussion rate per 1000 plays during kickoffs was 10.93 before and 2.04 after the rule change (difference, −8.88; 95% confidence interval [CI], −13.68 to −4.09).
The successful 2016 Ivy League rule change inspired the National Collegiate Athletic Association (NCAA) to alter its kickoff procedures. In 2018, the NCAA (including the Ivy League) implemented a new rule allowing players to call for a fair catch on kickoffs that fall inside the 25-yard line—the equivalent of a touchback, where the ball is placed at the 25. As of this writing, no study has analyzed the effects of this rule change.
Baseball
Although the overall incidence of mild traumatic brain injuries (mTBIs) in professional baseball is low (0.42 mTBI per 1000 AEs) compared with professional American football (6.61 mTBI per 1000 AEs), Green and colleagues demonstrated that greater than 40% of mTBIs occurred among catchers while fielding, and 40% of these injuries were caused by home plate collisions. In response to these findings, both Major League Baseball (MLB) and Minor League Baseball (MiLB) adopted a rule in 2014 to regulate home plate collisions, prohibiting runners from purposefully initiating contact with the catcher or catchers from blocking the runner pathway if not in possession of the ball. Green and colleagues performed a retrospective review of data entered into professional baseball’s electronic medical record system involving all active MLB and MiLB players from 2011 to 2017. Before the rule change (2011–13 seasons), a mean of 11 concussions attributed to home plate collisions occurred annually, compared with 2.3 per year following the rule change (2014–17 seasons) [ P = .0029], with no MLB concussions due to home plate collisions following the rule change. The mean number of days per season missed due to concussion resulting from home plate collisions decreased from 276 before 2014 to 36 per season after 2014 ( P = .0001).
Ice Hockey
Body checking in ice hockey is a legal strategy for adolescent and adult male participants to separate a player from the puck. Given the increased risk of injury including concussion associated with body checking, its role in youth ice hockey has been deliberated in past decades. In 2010, Emery and colleagues compared concussion injury risk between Pee Wee (age 12 years and younger) youth ice hockey players in the Canadian provinces of Alberta, in which body checking was allowed, and Quebec, in which body checking was not allowed. The investigators found a greater than 3-fold increased risk of concussion and all game-related injury (including severe concussion with time loss >10 days and severe injury with time loss >7 days) in the Alberta league compared with the Quebec league. Influenced by Emery’s study findings, USA Hockey and Hockey Canada eliminated body checking at the 12-and-under level in 2011 and 2013, respectively.
Another rule change in ice hockey implemented to reduce head and cervical spine injury involves Fair Play (FP) rules. Considered a behavior modification program focused on eliminating intent-to-harm, head contact, and “targeting” behavior in collision sports, FP rule changes use team or individual player penalties to promote sportsmanship by positively reinforcing assertive play (eg, controlled play, no intent-to-injure behavior) and negatively reinforcing aggressive play (eg, hits to the head, checking from behind). Initiated in Nova Scotia and Quebec, FP has been used by Minnesota Hockey since 2004 and recently has been implemented in high school boys’ hockey in Rhode Island.
Variations of FP rules and rule application exist in ice hockey. In the traditional model, points are rewarded to (or withheld from) teams that stay below (or exceed) a given number of penalty minutes allotted in a game. Team standings and tournament results are determined not only by wins and losses but also by team FP points. Roberts and colleagues have published results evaluating the effectiveness of FP rules reducing injury in ice hockey. During a 1994 Junior Gold Hockey (19-year-old and under and enrolled in high school) tournament in Minnesota, FP rules were used for 24 round-robin games, whereas regular rules (RR) were used for the tournament’s championship round (7 games). The FP/RR injury ratio was 1:4.8, the average number of penalties per game was 7.1 in FP compared with 13 in RR, and the number of rough play/injury penalties was 4 times higher in RR games.
In 2015, the Rhode Island Interscholastic League implemented an FP rule change in boy’s high school ice hockey that suspended individual players who accumulated greater than or equal to 50 penalty minutes (PIM) for 2 league games. Players who accumulated an additional 20 PIM (≥70 PIM) were suspended for the remainder of the season (including playoffs). Kriz and colleagues collected injury data from hospital systems and game/penalty data from the Rhode Island Hockey Coaches Association during 3 seasons before the rule change (2012/13–2014/15) and 3 seasons following the rule change (2015/16–2017/18). The PIM rule change was associated with a significant reduction in all injuries (odds ratio [OR], 0.55; 95% CI, 0.35–0.86), concussion/closed head injury (OR, 0.44; 95% CI, 0.23–0.85), and combined subgroups of concussion/closed head injury and upper body injury (OR, 0.50; 95% CI, 0.31–0.80).
Other strategies that reduce ice hockey collision may have the potential to reduce concussion risk. Larger rink size tends to spread out game play and separate players. In a study looking at injury data from the Ontario Junior A Hockey League (ages 16–20 years old), game injury rates were inversely related to ice surface size ( P <.01). Neurotraumas per game and aggressive penalty data did not show any difference related to ice rink size. The World Junior Championships were played on different size rinks in 3 successive years (2002–2004). Wennberg used game video to assess player collisions and head impacts. The larger ice sheet had less collision and less head injury compared with intermediate and smaller size rinks.
Decreasing the number of players on the ice may also reduce injury by spreading out the players. A historical precedent occurred when the team size, Silver Sevens (7 on a side), was reduced to 6 on a side, dropping the “deep center” position. On small rinks, 4 skaters plus the goalie on each side would functionally “enlarge” the skating surface.
Another strategy aimed at reducing flagrant penalties and modifying player behavior is to institute injury suspensions for illegal activities that lead to injury, where the injuring player would be prohibited from playing in the league until the injured player returned to the roster at full capacity plus an additional game restriction (ie, flagrant injury penalty = injury time off for the injured player + 3 games). Soccer and basketball rules require players who accumulate more than 2 to 4 penalties per game, respectively, to leave the game, and a similar strategy might be effective in ice hockey. These strategies require that officials call games uniformly and strictly enforce the rules.
Soccer
In soccer, yellow and red cards are used to discipline players for illegal play during game play. Yellow card accumulation policies (YCPs), which suspend players and/or coaches for illegal play or misconduct, have been used by soccer federations internationally as well as at the state level in the United States, to discourage foul play and disqualify individual players and teams from playoff participation if yellow card foul thresholds are exceeded. Despite YCPs being used in high school boys’ and girls’ soccer for more than 25 years in the United States, the effectiveness of YCPs as an injury prevention strategy had not been formally evaluated until recently. Kriz and colleagues studied National Federation of State High School Associations YCPs and high school soccer competition injuries during seasons 2005/06 through 2017/18, with injury and AE data collected from High School RIO. There was no significant difference in injury rates between schools in states with and without YCPs. Among states with YCPs, injury rates were not significantly different between pre- and post-YCP implementation. Although a significantly lower proportion of injuries that resulted in greater than 3 weeks’ time loss occurred in states with YCPs, no significant differences were observed in proportions of concussions, fractures, anterior cruciate ligament injuries, or injuries, resulting in surgery between states with/without YCPs. The investigators concluded that contrary to their intended impact, YCPs were not effective in lowering high school soccer competition–related athlete-athlete contact injury rates and that implementation of YCPs alone, without proper enforcement, may not be a sufficient injury prevention strategy (Kriz PK, Yang J, Arakkal A, et al. Fair play as an injury prevention intervention: do yellow card accumulation policies reduce high school soccer injuries? 2020. Submitted for publication).
Educational programs
Sport governing bodies and medical organizations such as the Center for Disease Control and Prevention have recently stepped up their educational campaigns aimed at collision and body contact in youth sports, developing multimedia educational messages and online training programs for coaches, players, and parents. , Critics of these educational efforts have raised concerns that educational campaigns are largely ineffective if knowledge transfer and action stages do not occur. Educational program outcomes have primarily been evaluated using surveys, questionnaires, and quizzes; qualitative methods rarely have been implemented. Although studies report short-term improvement in participants’ knowledge and attitudes, long-term benefits of educational programs are less clear. Kroshus and colleagues surveyed 146 players on 6 Division I male ice hockey teams before and after the players had received NCAA-mandated concussion educational interventions. Five teams had received education in a handout/e-mail format, whereas one team viewed an educational video. The investigators found that no significant improvements in concussion knowledge occurred among players and only a very small decrease in intention to continue playing with concussion. Kerr and colleagues evaluated the effectiveness of USA Football’s Heads Up Football (HUF) coaching education program and practice contact restriction in 2108 youth American football players aged 5 to 15 years participating in leagues using HUF programs, leagues without HUF programs (NHUF), and leagues implementing Pop Warner (PW) practice contact restrictions over a single season. Concussion rates during practice were lower in leagues that used both HUF and PW contact restrictions (HUF + PW) compared with NHUF leagues. HUF leagues saw no change in injuries sustained during games unless they also used PW practice restrictions (HUF + PW).
Cusimano and colleagues assessed concussion knowledge among 503 survey respondents before and after exposure to one or more of 19 SRC education resources introduced through a Canadian national initiative. Concussion knowledge scores (CKS) were calculated for pre- and postexposure. Respondents in the postsurvey had higher CKS than those in presurvey. Two out of 19 resources and 4 out of 6 modes of concussion education delivery (Web pages, written guidelines, phone apps, in-person resources, but not quizzes or videos) were successful in improving concussion knowledge, with Web page educational resources being the most effective delivery mode. In addition, using 3 or more resources was predictive of a statistically significant increase in CKS compared with using a single resource.
Legislation
The Zackery Lystedt Law passed by the State of Washington in 2009 has been model legislation for sport concussion law. Within 5 years of its passage, all 50 states and the District of Columbia have adopted youth sports concussion laws. The Lystedt Law has 3 basic tenets: (1) education of athletes, parents, and coaches, (2) removal from practice/play a suspected concussion at time of injury, (3) medically supervised return to play. However, significant variability regarding delivery of concussion education continues to exist among states. Although some states have explicitly mandated annual education of coaches, the Lystedt Law, as written does not directly mandate coach education. In addition, not all states require athlete, parent, and coach education. Variability also exists among states regarding which licensed health care providers trained in concussion management can medically clear concussed athletes, as many states have rural and underserved areas necessitating nonphysician providers be directly involved in concussion evaluation and management. Sports medicine providers should be familiar with their respective state’s concussion laws and interpretation, as well as their communities’ emergency action plans before engaging in game and event coverage.
Physiologic strategies to reduce concussion
Neck Strengthening
Neck strengthening exercises—historically an integral part of strength and conditioning among American football players and wrestlers—have recently received renewed attention as a prevention strategy for concussion among contact/collision sport athletes. Collins and colleagues recently assessed neck strength and neck circumference measurements in more than 6700 high school athletes over a 2-year period. Concussed athletes had (1) smaller neck circumferences compared with athletes who did not report concussion over the study period, (2) smaller neck circumferences and larger head circumferences compared with nonconcussed athletes, and (3) less neck strength compared with nonconcussed athletes. The investigators determined that for every pound increase in neck strength, odds of concussion decreased by 5% (OR = 0.95, 95% CI 0.92–0.98).
In addition to neck strengthening, anticipating collision has been proposed as a prevention strategy to reduce risk of SRC. Eckner and colleagues performed a biomechanical study in 46 male and female contact sport athletes aged 8 to 30 years. Maximum isometric neck strength was measured in various anatomic planes, and a loading apparatus then applied impulsive forces to the athletes’ heads during both baseline and anticipatory cervical muscle activation conditions. The investigators determined that greater isometric neck strength and anticipatory activation were independently associated with decreased head peak linear velocity and peak angular velocity after impulsive loading across all planes of motion. The study concluded that neck strength and impact anticipation are potentially modifiable risk factors for SRC and suggested that interventions aimed at increasing neck strength and that reducing unanticipated head and body impacts may reduce SRC incidence among contact/collision sport athletes.
Vision Training
There is emerging evidence that vision training has potential as a concussion injury risk reduction tool. Clark and colleagues examined the effectiveness of a preseason vision training (VT) program (light board training, strobe glasses, and tracking drills) in a Division I American football team over 4 seasons. Concussion incidence was compared with the previous 4 consecutive seasons. A statistically significant lower concussion rate was noted in players who underwent VT compared with those who did not (1.4 concussions per 100 player seasons vs 9.2 concussions per 100 game exposures, P ≤.001). Limitations include retrospective study design, lack of randomization, no control group, small sample size, and nonuniform denominator measures of AE.
Jugular Vein Compression
In recent years, attention has been directed to novel approaches that may protect an athlete’s brain from within by decreasing brain “slosh” during impact. Academic and industry researchers alike are investigating biomechanical modifications to cerebral blood flow. Placing a collar around an athlete’s neck applies mild bilateral jugular vein compression (or occlusion) that diverts blood flow to the vertebral veins, prompting cerebral engorgement. The venous cerebral engorgement theoretically reduces intracranial energy absorption associated with head impact exposures, preserving integrity of brain white matter, which is susceptible to structural alterations as a result of concussive or subconcussive impacts. Proponents, including developers of commercial collars, have likened this physiologic modification to the woodpecker’s mechanism for protecting its brain. However, critics have challenged this claim, stating that nowhere in the woodpecker literature is such an evolutionary adaptation actually described or hypothesized.
Nonetheless, several recent studies pertaining to jugular compression have been published. Meyer and colleagues performed a prospective longitudinal neuroimaging study involving 50 high school female soccer players divided into collar-wearing and noncollar groups; collars were worn during games and practices during their competitive season. All underwent pre- and postseason MRI and diffuse tensor imaging (DTI) evaluation. Head impacts were monitored using wearable patch accelerometers. DTI analyses showed significant preseason to postseason white matter changes in the noncollar group, which resolved partially at 3 months off-season follow-up. No significant white matter changes were detected in the collar group despite similar head impact exposure, suggesting a potential prophylactic effect of the collar in preventing microstructural changes associated with repetitive head impacts. Limitations of the study included potential confounding of hormonal fluctuations (hormonal cycling on intracranial pressure/volume, potential neuroprotective effect of progesterone after a TBI) and lack of correlation between DTI changes and athletes’ physical or cognitive function.
Sport culture change
Several disturbing trends regarding sport culture persist in athletic communities and potentially contribute to SRC risk. Single-sport specialization in youth and adolescent sports, in which athletes play on multiple teams and attend numerous showcases in pursuit of college scholarships, not only has contributed to the epidemic of overuse injuries but is also a likely factor in concussion risk/susceptibility, as windows of opportunity for brain recovery following head impacts have become narrower as most sports have become 3-season or year-round commitments.
Educational institutions and organizations are also responsible for cultural changes in sport. In recent years, several Division I universities have offered college scholarships to eighth-grade football players, and verbal commitments by high school underclassmen to play Division I sports are commonplace. , Such early commitments consequently create a culture of increased AEs at a younger age, transferring a higher volume and intensity of participation to a less physically mature population—an unintended consequence that has not been acknowledged in the literature but is apparent to clinicians treating these athletes. The NCAA has recently adopted rules to address early recruitment practices in Division I athletics, creating a “phased-in” recruiting approach that allows coaches to build relationships with prospective student-athletes through phone/electronic communication before allowing for visits and off-campus contact. Although some of the impetus of the rule change is to prevent early recruitment, variability between individual sports’ recruiting rules remains. Men’s ice hockey, for example, continues to allow contact with prospective student-athletes during January of sophomore year. With more athletes “reclassifying”—repeating grades in order to gain physical maturity and size/stature advantages over their peers—additional age, size, and physical maturity discrepancies have been created in contact/collision sports at the adolescent level. Collectively, these developments have inevitably resulted in more athletes and their families risking recurrent, cumulative injury including SRC, hoping for a payoff in the form of a college athletic scholarship. As a result, sports medicine providers are treating more adolescent athletes with multiple concussions who are in jeopardy of being retired from sport early in their high school careers.
As skill level and competition for Division I ice hockey scholarships has increased, so has a trend for high school players to hone their skills in elite junior programs in the United States in an effort to continue their hockey careers at a US university or college. Just as professional ice hockey leagues, junior leagues permit fighting, a known risk factor for SRC and related complications including cognitive impairment. Some of these junior program players accumulate recurrent SRC, which jeopardizes both their athletic and academic futures.
Summary
Preventive strategies to reduce concussion risk in sport continue to evolve. Over the past decade, scientific evaluation of concussion prevention strategies has become more rigorous providing higher-quality evidence to judge the efficacy of the interventions. Technological advancements in fields such as neuroimaging and wearable accelerometers allow researchers to collect and disseminate information involving the effects of sport-related head impacts to athletes, coaches, and sports organizations. Inevitably, future directions in reducing concussion risk in sport will include commonsense interventions such as rule changes, behavioral modifications, and cultural change, which will become easier to implement as research critically evaluates their impact on sport concussion reduction. Educational programs will continue to play an integral role in reducing concussion risk, and transferring concussion knowledge into action that effectively reduces concussion will continue to be a high priority.
In the future, athletes, parents, coaches, and sport governing bodies will need to assess acceptable versus unacceptable injury to help set policy regarding higher risk activities within sport. It is clear that ice hockey is safest with no body checking or fighting; however, sport governing bodies have been slow to implement these simple interventions. Player attitude is also critical to safety, and as long as “bad behavior” is tolerated, the players who do follow the rules will be at risk from others who do not comply. Using “Fair Play” systems that reward teams abiding by the rules and punish individuals who break the rules is a simple strategy that has made a difference in some settings. Ultimately, a combination of rules compliance and strict enforcement works best for player safety and concussion reduction.
Disclosure
The authors have nothing to disclose.
References
Related posts:
Epidemiology of Sport-Related Concussion
Biomechanics of Sport-Related Neurological Injury
Rehabilitation of Sport-Related Concussion
Neuroimaging in Sports-Related Concussion
Considerations for Athlete Retirement After Sport-Related Concussion
Future Directions in Sports-Related Concussion Management
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