Return to play after head injury in adolescent sports: evaluating football versus other sports

Bahie Ezzat Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Bahie Ezzat in
jns
Google Scholar
PubMed
Close
 MS
,
Eugene I. Hrabarchuk Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Eugene I. Hrabarchuk in
jns
Google Scholar
PubMed
Close
 BS
,
Alexander J. Schupper Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Alexander J. Schupper in
jns
Google Scholar
PubMed
Close
 MD
,
Addison Quinones Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Addison Quinones in
jns
Google Scholar
PubMed
Close
 BS
,
Muhammad Ali Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Muhammad Ali in
jns
Google Scholar
PubMed
Close
 MSCR
,
Michael B. Lemonick Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Michael B. Lemonick in
jns
Google Scholar
PubMed
Close
 MA
,
Benjamin Rodriguez Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Benjamin Rodriguez in
jns
Google Scholar
PubMed
Close
 BS
,
Alex Gometz Concussion Management of New York, New York, New York; and

Search for other papers by Alex Gometz in
jns
Google Scholar
PubMed
Close
 DPT
,
Mark Lovell Department of Neurology, University of Pittsburgh, Pennsylvania

Search for other papers by Mark Lovell in
jns
Google Scholar
PubMed
Close
 PhD
, and
Tanvir Choudhri Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York;

Search for other papers by Tanvir Choudhri in
jns
Google Scholar
PubMed
Close
 MD
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $536.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $536.00
USD  $636.00
Print or Print + Online Sign in

OBJECTIVE

Increased adolescent sports participation has raised concerns about higher rates of concussions, a prevalent injury among young athletes with potential long-term effects. Discrepancies in concussion recovery and management protocols across various sports underscore a critical issue in youth athletics. This study aimed to examine the relationship between sport type and the number of games missed following a concussion to inform targeted management strategies.

METHODS

Data from 7445 postinjury ImPACT tests for athletes aged 12–22 years, collected from 2009 to 2019, were analyzed across different sports: baseball, basketball, cheerleading, football, ice hockey, lacrosse, soccer, softball, swimming, track and field, volleyball, and wrestling. The number of days and normalized missed games (NMG), a metric accounting for the different number of games in a season for different sports, were used to evaluate the effect of concussions across different sports. ANOVA, t-tests, and linear regression analyses were performed to model the effect of sport type on games missed in a season while controlling for sex, age, concussion history, diagnosed learning disability (DLD), and attention-deficit/hyperactivity disorder (ADHD).

RESULTS

Multivariable linear regression analysis demonstrated that football participation significantly increased NMG (β 1.681, 95% CI 0.807–2.554; p < 0.001) and days missed (β 1.637, 95% CI 1.044–2.231; p < 0.001) after head injury. Concussion diagnoses were also found to significantly increase NMG (β 2.344, 95% CI 1.629–3.059; p < 0.001) and days missed (β 1.560, 95% CI 1.074–2.045; p < 0.001), as well as history of prior concussion (NMG: β 7.791, 95% CI 7.368–8.215; p < 0.001; days missed: β 5.232, 95% CI 4.945–5.520; p < 0.001). In contrast, factors such as age, sex, DLD, ADHD, and concussions causing loss of consciousness did not significantly affect NMG or days missed. ANOVA with Tukey Honest Significant Difference indicated that compared with football, ice hockey (mean difference [MD] 5.4 days, p = 0.011) and track and field (MD 4.1 days, p = 0.006) were associated with significantly more days being missed after head injury. Conversely, basketball (MD −3.0, p < 0.001) and volleyball (MD −2.6, p = 0.005) were associated with fewer missed games.

CONCLUSIONS

Adolescents playing football missed fewer days and games after concussion than other contact and noncontact sports, including ice hockey and track and field, raising questions about variations in return-to-play protocols and cultural attitudes within sports. Further research is needed to determine the factors affecting games missed across sport types in adolescent athletics and return-to-play protocols.

ABBREVIATIONS

ADHD = attention-deficit/hyperactivity disorder; CC = concussion cohort; DLD = diagnosed learning disability; HSD = Honest Significant Difference; ImPACT = Immediate Post-Concussion Assessment and Cognitive Testing; LOC = loss of consciousness; MD = mean difference; NCC = nonconcussion cohort; NMG = normalized missed games; PCSS = Post-Concussion Symptom Scale; RTP = return to play; Sdiff = standard error of difference at the 80% confidence interval; SI = Severity Index.
  • Collapse
  • Expand
  • 1

    Powell JW, Barber-Foss KD. Injury patterns in selected high school sports: a review of the 1995-1997 seasons. J Athl Train. 1999;34(3):277284.

  • 2

    Logan K, Cuff S. Organized sports for children, preadolescents, and adolescents. Pediatrics. 2019;143(6):e20190997.

  • 3

    McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5th International Conference on Concussion in Sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838847.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Broshek DK, De Marco AP, Freeman JR. A review of post-concussion syndrome and psychological factors associated with concussion. Brain Inj. 2015;29(2):228237.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Rivara FP, Ebel BE, Binjolkar M. cognitive impairment and driving skills in youth after concussion. J Neurotrauma. 2023;40(11-12):11871196.

  • 6

    High school sports. NCSA College Recruiting. Accessed March 27, 2004. https://www.ncsasports.org/articles-1/high-school-sports

  • 7

    Veliz P, McCabe SE, Eckner JT, Schulenberg JE. Prevalence of concussion among US adolescents and correlated factors. JAMA. 2017;318(12):11801182.

  • 8

    Powell JW, Barber-Foss KD. Traumatic brain injury in high school athletes. JAMA. 1999;282(10):958963.

  • 9

    Li AY, Schupper AJ, Quinones A, et al. Sport contact level affects post-concussion neurocognitive performance in young athletes. Arch Clin Neuropsychol. 2022;37(1):1929.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747755.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F. Sports- and recreation-related concussions in US youth. Pediatrics. 2016;138(1):e20154635.

  • 12

    May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA. Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther. 2014;9(2):242255.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Patricios J, Fuller GW, Ellenbogen R, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med. 2017;51(11):888894.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Halstead ME, Walter KD. American Academy of Pediatrics. Clinical report—sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597615.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Jenco M. CDC releases new guidance on diagnosing, managing concussions. AAP News. September 10, 2018. Accessed March 27, 2024. https://publications.aap.org/aapnews/news/7988/CDC-releases-new-guidance-on-diagnosing-managing

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Patricios JS, Schneider KJ, Dvořák J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med. 2023;57(11):695711.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr. 2003;142(5):546553.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol. 2006;21(1):9199.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Iverson GL, Lovell MR, Collins MW. Interpreting change on ImPACT following sport concussion. Clin Neuropsychol. 2003;17(4):460467.

  • 20

    Meehan WP III, Mannix RC, O’Brien MJ, Collins MW. The prevalence of undiagnosed concussions in athletes. Clin J Sport Med. 2013;23(5):339342.

  • 21

    Hannah T, Dreher N, Li AY, et al. Assessing the predictive value of primary evaluation with the Immediate Post-Concussion Assessment and Cognitive Test following head injury. J Neurosurg Pediatr. 2020;26(2):171178.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Quinones A, Young T, Schupper AJ, et al. Effects of repetitive head trauma on symptomatology of subsequent sport-related concussion. J Neurosurg Pediatr. 2023;32(2):133140.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344349.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    GraphPad Prism version 10.0.0 for Windows, GraphPad Software. Accessed March 27, 2024.www.graphpad.com

  • 25

    FHSAA board cuts number of high school games allowed. NorthEscambia.com. Accessed March 27, 2024. http://www.northescambia.com/2009/04/fhsaa-board-cuts-number-of-high-school-games-allowed

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Zuckerman SL, Kerr ZY, Yengo-Kahn A, Wasserman E, Covassin T, Solomon GS. Epidemiology of sports-related concussion in NCAA athletes from 2009-2010 to 2013-2014: incidence, recurrence, and mechanisms. Am J Sports Med. 2015;43(11):26542662.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Kerr ZY, Roos KG, Djoko A, et al. Epidemiologic measures for quantifying the incidence of concussion in National Collegiate Athletic Association sports. J Athl Train. 2017;52(3):167174.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941948.

  • 29

    Emery CA, Black AM, Kolstad A, et al. What strategies can be used to effectively reduce the risk of concussion in sport? A systematic review. Br J Sports Med. 2017;51(12):978984.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Comstock RD, Currie DW, Pierpoint LA, Grubenhoff JA, Fields SK. An evidence-based discussion of heading the ball and concussions in high school soccer. JAMA Pediatr. 2015;169(9):830837.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Meehan WP III, Mannix R. Pediatric concussions in United States emergency departments in the years 2002 to 2006. J Pediatr. 2010;157(6):889893.

  • 32

    Gil-Jardiné C, Al Joboory S, Jammes JTS, et al. Prevention of post-concussion-like symptoms in patients presenting at the emergency room, early single eye movement desensitization, and reprocessing intervention versus usual care: study protocol for a two-center randomized controlled trial. Trials. 2018;19(1):555.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Kroshus E, Garnett B, Hawrilenko M, Baugh CM, Calzo JP. Concussion under-reporting and pressure from coaches, teammates, fans, and parents. Soc Sci Med. 2015;134:6675.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Kaminski TW, Wikstrom AM, Gutierrez GM, Glutting JJ. Purposeful heading during a season does not influence cognitive function or balance in female soccer players. J Clin Exp Neuropsychol. 2007;29(7):742751.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Graham R, Rivara FP, Ford MA, et al. Consequences of repetitive head impacts and multiple concussions. In: Graham R, Rivara FP, Ford MA, Spicer CM, eds. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. National Academies Press; 2014.Accessed March 27, 2024. https://www.ncbi.nlm.nih.gov/books/NBK185336/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Graham R, Rivara FP, Ford MA, et al. Concussion recognition, diagnosis, and acute management. In: Graham R, Rivara FP, Ford MA, Spicer CM, eds. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. National Academies Press; 2014.Accessed March 27, 2024. https://www.ncbi.nlm.nih.gov/books/NBK185340/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Talavage TM, Nauman EA, Breedlove EL, et al. Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion. J Neurotrauma. 2014;31(4):327338.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Maas AIR, Menon DK, Adelson PD, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):9871048.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Baugh CM, Kiernan PT, Kroshus E, et al. Frequency of head-impact-related outcomes by position in NCAA division I collegiate football players. J Neurotrauma. 2015;32(5):314326.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Dioso E, Cerillo J, Azab M, et al. Subconcussion, concussion, and cognitive decline: the impact of sports related collisions. J Med Res Surg. 2022;3(4):5463.

  • 41

    Huber BR, Alosco ML, Stein TD, McKee AC. Potential long-term consequences of concussive and subconcussive injury. Phys Med Rehabil Clin N Am. 2016;27(2):503511.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): background and rationale. Br J Sports Med. 2017;51(11):848850.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Pavlovic D, Pekic S, Stojanovic M, Popovic V. Traumatic brain injury: neuropathological, neurocognitive and neurobehavioral sequelae. Pituitary. 2019;22(3):270282.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: physician’s chart review. Can Fam Physician. 2014;60(6):e310,e312-315.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):22502257.

    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 548 548 548
Full Text Views 61 61 61
PDF Downloads 82 82 82
EPUB Downloads 0 0 0