Epidemiology of Concussion in Collegiate and High School Football Players
abstract & commentary
Synopsis: The rate of concussion in high school football is more than twice the rate in division I collegiate football, and high school and collegiate football players are nearly three times more likely to sustain a second concussion in the same season as those players who have not sustained a previous injury.
Source: Guskiewicz KM, et al. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med 2000;28(5):643-650.
Previous studies have reported concussion rates as high as 20% in high school football players and 10% in collegiate football players. This paper sought to determine: 1) the incidence of concussion in high school and collegiate football; 2) common signs and symptoms, mechanisms of injury, and positions at risk; and 3) return-to-play decisions following concussion. A national random sample of 392 certified athletic trainers (ATC) from high school and division I, II, and III colleges participated in the study. The ATCs were asked to complete a concussion report immediately after any concussion sustained by an athlete. Concussion was defined as an acceleration or deceleration injury accompanied by posttraumatic impairment of neural function (e.g., alteration of consciousness, blurred vision, dizziness, amnesia, or memory impairments). The Cantu concussion classification system was used to classify degree of injury.1 Total athlete-exposure per team was calculated as the product of the total number of practices or games and the number of players on the team. Contact athlete-exposure was also determined and was calculated by summing the number of contact practices and the number of games.
A total of 17,549 football players were represented at 242 schools and, of these players, 888 sustained at least one concussion. Of these injuries, 131 sustained a second injury during the same season. A chi-square test revealed incidence of injury per total athletes was higher at the high school and collegiate division III level than at the division I and II levels. Grade I concussions were the most common type (89.9%) followed by grade II (10.6%) and grade III (0.4%). Of 101 injuries occurring from contact with the ground, 17.8% occurred on artificial turf and 82.2% occurred on natural grass. However, four of the head injuries with artificial turf resulted in grade II concussion, and seven with natural grass resulted in a grade II injury. The study found the most common signs and symptoms associated with concussion were headache (86%), followed by dizziness (67%) and confusion (59%). It was also noted that concussion is rarely associated with loss of consciousness (8.9%). Seventy-one percent of the return-to-play decisions were made collectively by a team physician and an ATC. Nearly one-third (30.8%) of the head-injured players returned to participation on the same day of injury. The average time players who returned and were withheld from competition was 13 minutes.
COMMENT BY DAVID H. PERRIN, PhD, ATC
This study found a slightly lower incidence of concussion in high school and collegiate football players than has previous studies. Nevertheless, the study reaffirms the problem of concussion in sport, and the challenges these injuries pose for the medical team making return-to-play decisions. It also confirms the clinical impression that players receiving an initial concussion are far more likely to sustain a second injury in the same season.
Several disturbing trends can be seen from the findings of this study. The incidence rate of head injury in athletes is highest at the level of competition where medical coverage is often the least comprehensive. Far too few high schools are staffed with ATCs, and many do not have the services of a qualified team physician. One can only imagine what the quality of care for athletes receiving a "dinger" must be at schools where coaches are making "medical" decisions.
The return of nearly one-third of head-injured players to participation within 13 minutes post-injury is also alarming. It seems likely that at least some players must have been returned in the presence of post-traumatic symptoms. To avoid the tragedy of second impact syndrome (which has its highest prevalence among high school aged populations), under no circumstances should athletes be returned to competition in the presence of post-traumatic symptoms such as headache, dizziness, or confusion. The athlete should be free of these symptoms while at rest, and then also when assessed during sideline physical exertion.
It was also interesting to note that the severity of second-degree concussions was disproportionately higher when head contact was made with artificial turf in comparison to grass. Guskiewicz and colleagues did not measure nor establish a statistical relationship between severity of injury and playing surface. Nevertheless, one wonders if these observations are yet another indictment against the use of artificial turf for high school and collegiate football.
Reference
1. Cantu R. Guidelines for return to contact sports after a cerebral concussion. Phys Sportsmed 1986;14:75-83.
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