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Incidence of Concussion During Practice and Games in Youth, High School, and Collegiate American Football Players
Importance A report by the Institute of Medicine called for comprehensive nationwide concussion incidence data across the spectrum of athletes aged 5 to 23 years.
Objective To describe the incidence of concussion in athletes participating in youth, high school, and collegiate American football.
Design, Setting, and Participants Data were collected by athletic trainers at youth, high school, and collegiate football practices and games to create multiple prospective observational cohorts during the 2012 and 2013 football seasons. Data were collected from July 1, 2012, through January 31, 2013, for the 2012 season and from July 1, 2013, through January 31, 2014, for the 2013 season. The Youth Football Surveillance System included 118 youth football teams, providing 4092 athlete-seasons. The National Athletic Treatment, Injury and Outcomes Network program included 96 secondary school football programs, providing 11 957 athlete-seasons. The National Collegiate Athletic Association Injury Surveillance Program included 24 member institutions, providing 4305 athlete-seasons.
Exposures All injuries regardless of severity, including concussions, and athlete exposure information were documented by athletic trainers during practices and games.
Main Outcomes and Measures
Injury rates, injury rate ratios, risks, risk ratios, and 95% CIs were calculated.
Results Concussions comprised 9.6%, 4.0%, and 8.0% of all injuries reported in the Youth Football Surveillance System; National Athletic Treatment, Injury and Outcomes Network; and National Collegiate Athletic Association Injury Surveillance Program, respectively. The game concussion rate was higher than the practice concussion rate across all 3 competitive levels. The game concussion rate for college athletes (3.74 per 1000 athlete exposures) was higher than those for high school athletes (injury rate ratio, 1.86; 95% CI, 1.50-2.31) and youth athletes (injury rate ratio, 1.57; 95% CI, 1.17-2.10). The practice concussion rate in college (0.53 per 1000 athlete exposures) was lower than that in high school (injury rate ratio, 0.80; 95% CI, 0.67-0.96). Youth football had the lowest 1-season concussion risks in 2012 (3.53%) and 2013 (3.13%). The 1-season concussion risk was highest in high school (9.98%) and college (5.54%) in 2012.
Conclusions and Relevance Football practices were a major source of concussion at all 3 levels of competition. Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors.
JAMA Pediatr. 2015;169(7):659-665. doi:10.1001/jamapediatrics.2015.0210
Injuries occur in all sports, at all levels of play and in athletes of all ages. Historically, the long-term consequences of sports-related injuries have received little attention. At times, athletes, coaches, fans, and the media have perhaps provided apparent tacit acceptability of concussions and other injuries in sports by celebrating “highlight reel” hits and collisions and revering displays of “toughness” when injured players continue to compete. Consequently, a culture valuing playing through pain and winning at all costs has permeated athletics and de-emphasized personal safety. The recent lawsuit between former professional football players and the National Football League has brought national attention to the long-term consequences of sports-related head injuries and has led many to reevaluate the values idealized in athletics.
In response to the increasing concerns about player safety, significant policy changes have been implemented in youth, high school, and collegiate athletics nationwide. In 2009, Washington State enacted the Zackery Lystedt Law, which prohibited youth athletes from returning to practice or games after a concussion without the written approval of a licensed health care practitioner. Every state has implemented similar legislation since that time, and in 2010 the National Collegiate Athletic Association (NCAA) instituted a similar policy. In addition, multiple education and safety campaigns have been developed to help protect young athletes from sports-related brain injuries, including the Centers for Disease Control and Prevention’s HEADS UP initiative. However, most of these were created in the absence of thorough understanding of sports-related concussions and are not based on a strong body of evidence.
At this time, little is known about the long-term consequences of concussions in young athletes.1 However, among adults, concussions may be associated with an increased risk of developing neurodegenerative diseases such as Alzheimer disease, chronic traumatic encephalopathy, and perhaps even Parkinson disease.1 Although the evidence linking concussions to these neurodegenerative diseases remains controversial, it highlights the importance of conducting longitudinal research to better understand these potential consequences. In 2013, the Institute of Medicine (IOM) issued a report highlighting the need for a better understanding of sports-related concussions, their epidemiologic features in young athletes, and their long-term effects.2
A study published in the July 2015 issue of JAMA Pediatrics by Dompier et al3 responds to the IOM’s call to action by seeking to identify important epidemiologic features of concussions among young football players. Using data from 3 large injury-surveillance programs, the authors attempted to quantify the concussion burden in youth (5- to 14-year-olds, including 4092 athlete-seasons), high school (11 957 athlete-seasons), and collegiate (4305 athlete-seasons) football players. The study found that approximately 1 in 30 youth league football players, 1 in 14 high school football players, and 1 in 20 in collegiate football players sustained concussions each year. According to the authors’ projections, these findings estimate that 182 000 young football players sustain at least 1 concussion each year. In an analysis examining the distribution of concussion occurrence (practice vs game) within each of the 3 levels of play, the authors found that concussion rates were significantly higher in games at all levels, with the largest difference between practice and game concussion rates occurring in collegiate football.
The results of this study provide valuable insight into the overall burden of football-related concussions and reveal particularly high rates during games. Given the concerns over potential chronic sequelae of sports-related concussions, these findings reveal the number of young athletes who may be at risk. It also helps demonstrate the need for ongoing prevention, surveillance, and research and gives insight into how current efforts may be improved.
The study by Dompier et al3 was limited by one of the major challenges in studying and managing sports-related head injuries. Concussions were diagnosed in accordance with institutional, local, or state guidelines rather than a universal set of diagnostic criteria. Epidemiological evaluation of concussions requires standard diagnostic criteria. In their absence, lack of diagnostic uniformity may introduce nonrandom variability into incidence data and ultimately influence comparative and outcome-related analyses.
One of the inherent difficulties is that diagnosing concussions is largely clinical and often involves subjective assessments rather than objective testing.4 Concussion symptoms are largely subjective, and recognition often relies on athlete or family reporting. This further complicates diagnosis, as social desirability bias may influence reporting.5 The clinical symptoms of acute concussion may be somatic, cognitive, or emotional in nature and may include loss of consciousness, amnesia, slow reaction times, confusion, disinhibition, or headaches.6 Symptoms may last several hours to several weeks, with children and adolescents experiencing longer recovery times.6,7 However, the potential chronic symptoms of concussion may not present for several years, making it difficult to link those symptoms to the sentinel event.
It is recommended that a player demonstrating any features of concussion after a direct or impulsive transmission of force to the head undergo formal evaluation with a sideline assessment tool.6 Although a variety of assessment tools exist, they are not definitively diagnostic, and many have not been validated for use in younger athletes.6 In addition, the multitude of sideline assessment tools available to athletic trainers and health care professionals challenges efforts to achieve uniform evaluative information.
The analysis by Dompier et al3 of the distribution of young football players’ concussion burden is useful but somewhat limited because of variation in how concussion was diagnosed. To improve the quality of epidemiologic research in concussion injury, standard diagnostic criteria are needed, as is a reliable infrastructure for longitudinal data collection. Improving the quality of information about football-related concussion injury could help identify optimal management strategies and facilitate development of evidence-based, data-driven athlete safety policies and may help prevent young athletes from developing long-term consequences of concussions that have been the focus of so much recent attention.