Helmetless Tackling Training Intervention and Preseason Self-efficacy Effects on Head Impacts in Hawai'i High School Football.

OBJECTIVE: To determine how football head impacts are influenced by self-efficacy (SE), helmetless tackling intervention participation (IP), and years of experience (YE) playing football. DESIGN: Cross-sectional. SETTING: Three high schools. PARTICIPANTS: 120 (male; n = 118, female; n = 2, 15.57 ± 1.23 years) participants were recruited from 5 high school teams (3 varsity and 2 junior-varsity). INDEPENDENT VARIABLES: SE, days of IP, and YE playing tackle football. MAIN OUTCOME MEASURES: SE was measured using a 53-question survey and categorized into 5 subscales. The accumulation of total head impacts (THI) was measured using Riddell InSite Speedflex helmets (Elyria, OH) throughout the season. Head impact exposure (HIE) was standardized as a ratio of impacts per session (games, scrimmages, and practices). Multiple regression analyses tested the relationship between THI or HIE with the predictor variables. RESULTS: For THI, 22.1% was explained by the predictors (r = 0.470, r2 = 0.221). Intervention participation had a negative correlation (B = -4.480, P = 0.019), whereas confidence in performing proper tackling and blocking (SE1) (B = 3.133, P = 0.010) and >8 YE (B = 135.9, P = 0.009) positively correlated with THI. For HIE, 25.4% was explained by the predictors (r = 0.504, r2 = 0.254). Intervention participation negatively correlated (B = -0.077, P = 0.007), whereas SE1 (B = 3.133, P = 0.010) and >8 YE (B = 2.735, P ≤ 0.001) correlated positively with HIE. CONCLUSIONS: Increased head impacts were associated with less helmetless tackling participation, more than 8 YE, and more self-confidence in tackling ability. Increasing the amount of time athletes spend practicing proper tackling and blocking techniques to reduce head first and risky play is warranted to reduce the amount of head impacts received over time.

Head Impact Exposure in Hawaiian High School Football: Influence of Adherence Rates on a Helmetless Tackling and Blocking Training Intervention.

CONTEXT: High school football remains a popular, physically demanding sport despite the known risks for acute brain and neck injury. Impacts to the head also raise concerns about their cumulative effects and long-term health consequences. OBJECTIVE: To examine the effectiveness of a helmetless tackling training program to reduce head impact exposure in football participants. DESIGN: A three-year, quasi-experimental, prospective cohort (clinicaltrials.gov #NCTXXX) study. SETTING: Honolulu (XXX, XXX) area public and private secondary schools with varsity and junior varsity football. PATIENTS OR OTHER PARTICIPANTS: Football participants (n=496) ages 14 to 18 years old. Intervention(s) Participants wore new football helmets furnished with head impact sensor technology. Teams employed a season-long helmetless tackling and blocking intervention in Years 2 and 3 consisting of a 3-phase, systematic progression of 10 instructional drills. MAIN OUTCOME MEASURE(S): Head impact frequency per athlete exposure (ImpAE), location, and impact magnitude per participant intervention adherence levels (60% and 80%). RESULTS: An overall regression analysis revealed a significant negative association between ImpAE and adherence (p=0.003, beta=-1.21, SE=0.41). In year 3, a longitudinal data analysis of weekly ImpAE data resulted in an overall difference between the adherent and non-adherent groups (p=0.040 at 80%; p=0.004 at 60%), mainly due to decreases in top and side impacts. Mean cumulative impact burden for the adherent group (n=131: 2,105.84g ± 219.76,) was significantly (p=0.020) less than the non-adherent group (n=90: 3,158.25g ± 434.80) at the 60% adherence level. CONCLUSIONS: Participants adhering to the intervention on at least a 60% level experienced a 34% to 37% significant reduction in the number of head impacts (per exposure) through the season. These results provide additional evidence that a helmetless tackling and blocking training intervention (utilizing the HuTT® program) reduces head impact exposure in high school football players. Adherence to an intervention is crucial for achieving intended outcomes.

Assessing Concussion Knowledge Among Recreational Surfers and Comparing Results to Concussion Knowledge Among Soccer Players: A Pilot Study.

Concussions are caused by physical trauma to the head, face, or neck and can be sustained while surfing, increasing the risk of drowning. The purpose of this pilot study was to establish a preliminary assessment of concussion knowledge in a group of adult recreational surfers. Using the standardized Concussion Knowledge Index, an anonymous survey was conducted with 55 surfers. The Concussion Knowledge Index and similar statistical measures were used in a previous study of adult soccer players in England. Data from these 2 groups were compared. The preliminary data suggests that the group of adult surfers demonstrate more concussion knowledge than the group of adult soccer players. Further study into surfers' knowledge of concussion with a larger sample size could increase the clinical utility and generalizability of this study.

TEST-RETEST RELIABILITY AND RELIABLE CHANGE INDEX OF MOBILE APPLICATION NEUROCOGNITIVE TEST AMONG MIDDLE AND HIGH SCHOOL ATHLETES.

CONTEXT: A mobile application neurocognitive assessment has been used in place of equipment intensive computerized neurocognitive assessment protocol. A previous study reported high to very high test-retest reliability of neurocognitive assessment using the mobile application in healthy adults, but no studies have examined test-retest reliability, reliable change indices (RCIs), and sex effect in middle school and high school populations when conducted 1 year apart. OBJECTIVE: The purpose of this study was to examine the test-retest reliability and RCIs of baseline data collected at 2-time points approximately 1 year apart using a mobile application neurocognitive rest in middle school and high school athletes. The secondary purpose of the study was to investigate the sex difference in neurocognitive measures. DESIGN: Cross-sectional study. SETTING: Institutional. PATIENTS OR OTHER PARTICIPANTS: 172 middle school and high school healthy student-athletes (mean age=13.78±1.59 years old). MAIN OUTCOME MEASURE(S): Mobile application neurocognitive rest scores (reaction time, impulse control, inspection, and memory). RESULTS: The result from the study demonstrated that neurocognitive measures had low test-retest reliability across a 1-year time period in middle and high school settings. Upon retesting, reaction time and inspection time improved significantly in both middle and high school athletes, and impulse control showed significant improvement in middle school athletes. More athletes in middle school showed more RCI improvements compared to high school athletes. While both males and females demonstrated improvements in neurocognitive measures throughout adolescence, males outperformed females on reaction time and impulse control. CONCLUSIONS: Findings from the study indicate unacceptably low test-retest reliability of a mobile application neurocognitive test most likely due to cognitive development occurring throughout adolescence. Additionally, significant RCIs were noted. These naturally occurring improvements due to cognitive development could mask the post-concussion deficits. The findings warrant consideration of age and sex on the neurocognitive performance of middle and high school athletes.

Population-based normative data and language effects of the Immediate Post-Concussion Assessmentand Cognitive Testing (ImPACT).

OBJECTIVE: When test results are interpreted based on the norms of the U.S. population, misdiagnoses of neurocognitive impairment could occur with subgroups of individuals whose demographic characteristics differ from the overall population. The present study compared locally-based normative test data of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) of high school athletes in Hawaii, where diverse ethnicity and bilingualism are prominent, versus published test norms. METHOD: 8637 high school athletes in Hawaii underwent ImPACT baseline testing. Non-parametric group comparisons of age, sex, and language groups were performed. Classification ranges for the ImPACT Composite scores and Total Symptom of the Hawaii sample were presented in percentile ranks that corresponded to the published ImPACT normative tables. RESULTS: Mann-Whitney U Test indicated significant differences in ImPACT Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time Composite scores between age groups and sexes, although the effect sizes were small. Kruskal-Wallis H Test indicated no differences among the language groups. Percentile ranks of the Hawaii scores were predominantly similar to the ImPACT norms, except for Visual Motor Speed in the Impaired and Borderline ranges. CONCLUSION: The findings suggest that locally based normative data should be considered for sub-populations that may differ from the general population. Language factors, such as bilingualism, did not have significant effect on the ImPACT scores.

Concussion Epidemiology in Youth Sports: Sports Study of a Statewide High School Sports Program.

BACKGROUND: Current research on concussion incidence in youth athletes (age <18 years) is small and limited by variability in injury reporting and diagnostic methodology. HYPOTHESIS: Concussion injuries commonly occur in high school sports programs. The likelihood of concussion among student-athletes (aged 13-18 years) depends on the sport they are participating in as well as the sex of the athlete. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: A retrospective analysis of all Hawaii high school athletes aged 13 to 18 years participating in 14 sports from 2011 through 2017 was performed as part of a statewide standardized concussion assessment and management program. RESULTS: A total of 5993 concussions were identified among 92,966 athletes. The overall concussion rate was 0.96 (95% CI, 0.94-0.99). Girls' judo had the highest concussion rate (1.92; 95% CI, 1.68-2.17) followed by football (1.60; 95% CI, 1.53-1.66). The concussion rate for boys (1.0; 95% CI, 0.97-1.03) was higher than that for girls (0.91; 95% CI, 0.87-0.95); however, in 4 of the 5 sports in which both girls and boys participated, girls had a higher rate of concussion injury. CONCLUSION: The likelihood of concussion among student-athletes aged 13 to 18 years may be higher than previously thought and varies depending on sport and sex. CLINICAL RELEVANCE: Epidemiologic data on concussion injury in children and adolescents are useful in accurately determining the relative risks of high school sports participation and may be valuable in determining the appropriate allocation of health care and scholastic resources for student-athletes, as well as the impact of rule and training modifications designed to improve participant safety.

Concussion Recovery Timeline of High School Athletes Using A Stepwise Return-to-Play Protocol: Age and Sex Effects.

CONTEXT: Implementation of a stepwise return-to-play (RTP) protocol has become the standard management strategy for high school athletes to ensure a safe RTP after concussion. The detailed characteristics of the recovery timeline throughout the steps of an RTP protocol have not been delineated among the adolescent population. OBJECTIVE: To investigate the days spent in each step of the stepwise RTP protocol in an adolescent population and examine the effects of age and sex on recovery time. DESIGN: Cross-sectional study. SETTING: Local schools. PATIENTS OR OTHER PARTICIPANTS: Student-athletes from 57 schools. INTERVENTION(S): A total of 726 patients with concussion (age = 15.5 ± 1.2 years, males = 454, females = 272) were included. The 7-step RTP protocol consists of the following steps: (1) complete cognitive rest, (2) full return to school, (3) light exercise, (4) running progression, (5) noncontact training drills and weight training, (6) full-contact practice or training, and (7) return to game play. The data were obtained by certified athletic trainers as a part of the statewide standardized concussion-management protocol. MAIN OUTCOME MEASURE(S): Days spent in steps 0 to 6 as well as a breakdown of days by sex and age. RESULTS: The average total RTP days were 20.2 ± 13.9. Half of this time was spent in the return-to-school phase (steps 2-3: 10.2 ± 10.0 days). Compared with 17-year-old participants, younger participants (age = 14-16 years) took 3 or 4 days longer to start step 3 and to reach step 6 (P < .05). Females took longer to reach step 6 than males (21.6 ± 15.5 versus 19.3 ± 12.7 days) because they took longer to reach step 3 (14.7 ± 11.4 days) than males (13.0 ± 10.0 days; P < .05). CONCLUSIONS: Our study provides an estimated stepwise concussion recovery timeline for adolescent student-athletes. Clearance to start step 3 was the benchmark for the recovery timeline, as the duration of the exercise portion of the protocol was consistent across the age and sex groups.

Hawai'i Concussion Awareness & Management Program (HCAMP): Impact.

Concussion, also referred to as mild traumatic brain injury (mTBI), is caused by a direct or indirect blow to the head or body causing the brain to move rapidly within the skull, resulting in immediate, but temporary, brain dysfunction. Developing awareness and promoting concussion education can reduce the number of short and long-term injuries associated with sports and non-sports related concussions in Hawai'i. The purpose of this study was two-fold: (1) to describe the number of concussions in 67 Hawai'i high school athletic programs using the ImPACT database; and (2) to describe which contact and collision sports had the highest rate of concussions in 67 Hawai'i high schools. This was a retrospective study that described the number of concussions generated across school years 2010-2016, concussion data across 14 contact sports, and athletic exposure rating for the 14 contact sports. Data were analyzed and aggregated from a data-bank associated with the Hawai'i Concussion Awareness and Management program. Findings suggest that for Hawai'i high school student athletes' concussions increased from 2010-2013 with a gradual decrease from 2014-2016, specific sports had higher number of concussions (eg, football), and when evaluating concussion rate per 1000 exposures, girls' judo was the highest. These findings stress the need for continued data collection, monitoring, education/awareness and research that will reduce the number of concussions among student athletes.

Maximizing Recovery From Concussions for Youth Participating in Sports and Recreational Activities.

Concussions have become a public health issue. This public health concern has drawn the attention of many states in which laws were created to address concussions safety, recognition of signs and symptoms, immediate removal, medical clearance, and return-to-play protocols. Most state legislation focused on student athletes participating in organized sports. However, the rise in concussion can be directly attributed to children, youth, and adolescents participating in nonsports-related events. Maximizing recovery from a concussion involves implementing education programs that focus on recognition of symptoms, treatment, and return-to-learn options. Treatment strategies used to address concussed youth include physical and cognitive rest and minimizing external stimuli that can increase symptoms. Because learning is a direct outcome for all youth, a return-to-learn protocol based on a collaborative school-based team approach is suggested.