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.

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.

Comparison of neuropsychological test scores of high school athletes in high and low contact sports: A replication study.

This replication study re-examined the neuropsychological effects of participation in high and low contact youth sports. Modeled after a recently published investigation, two contact sport groups of participants ages 12 to 18 were formed based on the rate of concussion in their respective sport, with the assumption that more head impacts and neuropsychological effects occur in high contact sports that have a greater number of reported concussions as compared with low contact sports. The preseason baseline ImPACT neuropsychological test scores and symptom scores of non-concussed youth athletes in a High Contact Sport (football, n = 139) and a Low Contact Sport (basketball, baseball, soccer, wrestling, volleyball, paddling, and cheerleading, n = 57) were compared. The results revealed significantly poorer ImPACT test performances in visual motor speed and reaction time among high contact sport athletes compared to low contact sport athletes. No differences were found between the two groups in Verbal Memory, Visual Memory, and Total Symptom. These findings were identical to a recent study in which nonconcussed youth athletes in a high contact sport, that is, football, exhibited poorer neuropsychological test performance than their peers in low contact sports, that is, basketball, baseball, soccer, wrestling, and judo. This research replication verified the results of the prior study, and raises concerns that youth athletes exposed to repetitive head trauma may be at risk for lowered neuropsychological functioning, even without a reported concussive event.

Role of Native Language in Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) of Youth Athletes.

OBJECTIVE: The aim of this research was to examine the role of native language in the performance of youth athletes on a computerized neuropsychological test battery, the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). METHOD: The study compared the baseline test scores of 5545 participants whose native language was English versus 195 whose native language was not English. The mean age of the participants was 15.06 years. RESULTS: A multivariate analysis of variance revealed no differences in the five ImPACT Composite scores of the two language groups. CONCLUSION: Contrary to prior research, one cannot simply expect that non-native English speakers will do more poorly on ImPACT than native English speakers. Further research on the use of ImPACT with other non-native English-speaking youth athletes is recommended.

Are There Subconcussive Neuropsychological Effects in Youth Sports? An Exploratory Study of High- and Low-Contact Sports.

This exploratory study was designed to examine the neuropsychological effects of sports-related head trauma-specifically, repetitive subconcussive impacts or head blows that do not result in a diagnosable concussion. The researchers compared the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) neurocognitive test scores of 2 groups of nonconcussed youth athletes (n = 282), grouped according to the frequency of concussions in their respective sports, with the assumption that more subconcussive impacts occur in sports in which there are more reported concussions. The results indicated that high-contact-sport (football) athletes had significantly poorer performance in processing speed and reaction time compared with athletes in low-contact sports (wrestling, soccer, baseball, judo, and basketball). This study into the effects of repetitive subconcussive head trauma tentatively raises concern that participation in high-contact sports, even without evidence of a diagnosable concussion, could result in lowered neuropsychological functioning among high school athletes. Limitations of this exploratory research effort are discussed.

Two-year Test-Retest Reliability of ImPACT in High School Athletes.

This research evaluated the 2-year test-retest reliability of the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) neuropsychological battery, and clarified the need for biennial updated baseline testing of high school athletes. This study compared the baseline test scores of 212 non-concussed athletes that were obtained in Grade 9 and again 2 years later when they were in Grade 11. Regression-based methods indicated that 4 of the 5 ImPACT scores were stable over 2 years, as they fell within the 80% and 95% confidence intervals (CIs). The results suggested that updating baseline testing for high school athletes after 2 years is not necessary. Further research into the consistency of computerized neuropsychological tests over 2 years with high school athletes is recommended.

Effects of Two Concussions on the Neuropsychological Functioning and Symptom Reporting of High School Athletes.

To assess the effects of two sports-related concussions on neuropsychological functioning and symptom reporting, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was administered to 483 high school athletes. Three groups of athletes were determined based on the number of previous concussions: no concussion (n = 409), 1 concussion (n = 58), and 2 concussions (n = 16). The results showed that the three groups did not differ in terms of their ImPACT composite scores (Verbal Memory, Visual Memory, Reaction Time, and Processing Speed) and the Total Symptom Score. As there are only a few studies that have reported the sequelae of 2 concussions in high school athletes, it is premature to declare that a repeated concussion does not have persistent neurocognitive effects on high school athletes.

Neuropsychological test performance of Hawai'i high school athletes: Hawai'i ImPACT normative data.

OBJECTIVE: Establishing normative data of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) performance of high school athletes in Hawai'i. STUDY DESIGN: Pre-season ImPACT testing was performed on 751 participants in football, baseball, basketball, soccer, volleyball, softball, and track from 4 Oahu public high schools. The ImPACT composite scores included measures of Verbal Memory, Visual Memory Processing Speed, and Reaction Time. The descriptive statistical data collected were the group means, standard deviations, standard errors of measurement, distribution of scores and percentile ranks of (1) 262 boys ages 13 to 15; (2) 297 boys ages 16 to 18; and (3) 192 girls ages 13 to 18. RESULTS: The means and standard deviations of the 4 ImPACT composite scores for the 751 student-athletes in Hawai'i were similar to the ImPACT scores obtained from a master database of ImPACT test results. Although differences between the Hawai'i and mainland data were nonsignificant, there appeared to be a trend revealing somewhat lower scores in the Hawai'i sample of athletes. DISCUSSION: The similarity in ImPACT test performance of Hawai'i high school athletes as compared to the mainland normative data provides support for the applicability of this computerized neuropsychological battery in Hawai'i. However in view of a trend reflecting slightly lower ImPACT scores among Hawai'i participants, the use of the normative data produced by this study may be desirable in assessing Hawai'i high school athletes.