Abstract
The primary prevention of sport-related concussions (“SRCs”) has received significantly less scholarly attention from researchers and clinicians than other aspects of SRCs, such as SRC monitoring and management. Current research into strategies for primary concussion prevention focus on protective gear, proper technique, neck strengthening, rule changes, legislation, and education, especially in contact sports that pose the greatest SRC risk to participants, such as football, hockey, soccer, and rugby. To the frustration and surprise of many, such research has failed to prove the efficacy of the most seemingly obvious SRC prevention strategies in these areas. This is likely because there is no panacea to prevent SRCs, and no strategy is universally applicable across age, gender, and positions within the same sport. Ultimately, concussion prevention will require an overall shift in the attitudes of coaches, players, and spectators towards putting safety above competitiveness, for example, by promoting fair play rules and enforcing penalties for unsafe plays.
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Keywords
- Prevention strategies
- Safety
- Competitiveness
- Fair play
- Penalties
- Protective gear
- Technique
- Neck strengthening
- Rules
- Legislation
- Education
Clinical Case
A mother and father accompany their 14-year-old son to his preseason pre-participation physical for high school sports. They inquire if there are any strategies or interventions that the high school is implementing to prevent concussions.
The following discussion will provide an overview of prevention strategies developed to reduce SRCs among athletes.
Protective Gear
Question: Are helmets effective at preventing concussions?
Helmets and Headgear
There is consensus among researchers, clinicians, and industry professionals that proper equipment, particularly helmets and headgear, protect against head injuries. The American Medical Society for Sports Medicine, for example, endorses helmet use to reduce scalp lacerations, skull fractures, and intracranial bleeds [1]. For a helmet or headgear to prevent an SRC, it must attenuate linear and rotational acceleration, which are the primary underlying mechanisms of SRCs [2].
Researchers have not been able to prove that helmets reduce SRCs, notwithstanding anecdotal evidence to the contrary. Investigating the effect of helmets to reduce SRC has proven to be challenging, especially in football, hockey, and other team collision sports, due to co-variability and ethical issues around having cohorts of athletes sustain from wearing helmets and comparing the rate of concussions in this group with athletes that are wearing helmets [3]. Players wear a variety of helmet brands and models, and different helmets may perform better under certain circumstances or when used by athletes in specific positions.
Changes to helmet design often involve tradeoffs. For example, heavier helmets typically attenuate linear acceleration but are less comfortable and accelerate rotational momentum and the duration of such rotation [2]. Many new helmet designs significantly reduce direct focal external force transfers, but these designs have not been proven to prevent linear and rotational acceleration. Interestingly, some argue that wearing seemingly more protective equipment, such as full-face masks in hockey and thicker padding in football helmets may, in fact, increase risky behaviors in wearers stemming from a false sense of security thereby exposing them to a greater risk for SRCs and other injuries [1, 4].
Football
Question: Are there specific football helmets that prevent concussions?
Football helmet manufacturers have developed and continue to develop helmets incorporating new designs and materials intended to reduce SRCs. The National Football League (“NFL”), in conjunction with the National Football League Players Association, the NFL players’ union, conducts an annual laboratory test, the NFL/NFLPA Helmet Performance Test, which stimulates certain concussion-causing impacts to assess the performance of helmets worn by NFL players [5]. According to the 2019 NFL/NFLPA Helmet Performance Test, approximately 50% of NFL players upgraded to a better performing helmet after reviewing the study’s results, and those wearing top performing helmets reported fewer concussions [5]. Nevertheless, research unaffiliated with the NFL has failed to show a meaningful difference in the incidence of SRCs with newer helmet models [6].
Other Sports
Question: Should athletes in soccer and other sports wear headgear to prevent concussions?
Studies have found that ski and snowboard helmets provide protection against head injuries, but, as another study pointed out, the studies did not separate concussions from other head injuries when looking at their efficacy towards concussion prevention [3, 7, 8]. Several bicycle helmets, especially newer designs, have built-in mechanisms to reduce rotational head acceleration caused by an oblique impact [9,10,11]. Wearing headgear in soccer has been explored with conflicting evidence for SRC reduction benefit [12]. In the past, rugby headgear has not provided any protection against concussions [13]. However, newer headgear using a viscoelastic material has shown the ability to reduce linear and rotational impact energy in the test setting, which could potentially help reduce the rate of developing and the severity of concussions in rugby [14]. As stated above, the added protection may also inadvertently promote more aggressive and risky behavior.
Mouth Guards
Question: Do mouth guards have any affect in preventing or reducing the severity of concussions?
It is widely accepted that mouth guards protect against overall head injury, especially dental injuries, while playing contact sports. However, the effectiveness of mouth guards in reducing concussions specifically is less clear [15, 16]. A meta-analysis did suggest a nonsignificant trend towards a protective effect of mouth guards against concussions in contact sports, specifically when looking at basketball, ice hockey, and rugby [3].
Fit and Maintenance
Question: Is there any reputable sources to assist in properly fitting headgear?
Ensuring the proper fit of equipment is paramount. The use of an ill-fitting helmet, for example, is a risk factor for concussions with more symptoms and of longer duration [17]. The Centers for Disease Control and Prevention launched a mobile web-based application as part of their larger Heads Up: Concussion program to help find a properly fitting helmet for various sports [18]. It is also important to periodically inspect helmets, mouth guards, and other equipment throughout sports seasons in addition to at the beginning of each season and repair or replace whatever has become deformed, worn down, or no longer fits [17]. Moreover, designating a specific person to monitor for proper fit is essential, especially in youth and high school athletes where head size and hairstyle may change throughout the season.
Cost
Unfortunately, protective equipment in contact sports can be expensive. In 2016, The Gadsden Times, an Alabama newspaper, estimated that the cost of outfitting a high school football player for a practice and a game might be between $800 and $1000 [19]. The list price of the top-ranked helmet in the 2019 NFL/NFLPA Helmet Performance Test is $950 [20].
Such expenses typically present, at minimum, financial hardship to parents and/or school districts and may even bar youth participation in the sport altogether. Programs that help provide youth athletes or youth sports teams with new or gently used equipment, such as Good Sports [21], Sports Matter [22], and The Sports Shed [23], may help reduce these costs. Additional care is required to ensure that such equipment is appropriate and fits correctly [24].
Athlete Bias
Question: Do athletes use the safety-related equipment that is designed to reduce the risk of concussion?
Countless examples exist of professional athletes resisting safety-related equipment upgrades for behavioral and even cosmetic reasons [25, 26]. For example, the overwhelming majority of Major League Baseball pitchers do not wear protective liners and caps designed to protect them from dangerous line drives hit back at them. Such intransigence has been addressed through a combination of rule changes at professional and youth levels designed to socialize these players from a young age to the more protective equipment [27].
Technique
Question: Are organized sports organization incorporating skill instruction in an attempt to reduce the risk of sport-related concussions?
More than ever, organized sports have largely replaced neighborhood pickup games beloved by previous generations of Americans. While the proliferation of organized sport has its detractors and disadvantages, one potential benefit is an increase in opportunities for youth participants to learn proper techniques, especially in high-risk maneuvers associated with SRCs, such as football tackling, hockey body checking, and soccer heading [1, 28, 29].
Using this time for skill development and instruction instead of games may reduce SRCs. Athletes learn better body control to prepare them for the inevitable collisions that will occur when they grow older and join leagues that permit these maneuvers. Additionally, this training now incorporates sport-specific techniques to reduce head acceleration.
Football
USA Football, a youth football governing body, heavily promotes Heads Up Football (“HUF”), a series of online and in-person courses for coaches to learn about proper equipment fitting, tackling technique, and instruction in drills designed to reduce head contact [30]. HUF’s tackling module includes fundamentals of and systems for teaching shoulder tackling and draws on principles of rugby tackling, which does not use the head [31]. A 2015 study found that HUF reduced injury rates but The New York Times raised issues with how USA Football and the study’s authors presented certain data from that study [28, 32, 33]. Further, that study evaluated the entire HUF program so the efficacy, if any, of the HUF tackling model on reducing SRCs was debated. A more recent prospective study demonstrated a 33% reduction in SRC with HUF, providing some potential for benefit [34].
Soccer
Strategies to reduce head acceleration when heading the ball in soccer include achieving head-neck-torso alignment and neck strengthening (discussed below) [35, 36]. Other experts recommend using lightweight soccer balls to teach and perfect heading techniques [36]. In theory these recommendations make sense but lack the support of strong evidence-based clinical research.
Hockey
Coaching and education programs in the United States and Canada emphasize teaching youth to keep their heads up, especially when about to receive a check. Since the implementation of programs emphasizing these skills there has been a decrease in cervical spine injuries, but the effectiveness of these techniques have not been formally assessed [37]. USA Hockey’s American Development model emphasizes skill and skating development including proper body control, angling, and body contact but does not teach body checking skills until 11–12-year-old age group [37].
Neck Strengthening
Question: Do neck strengthening exercise prevent concussions?
Small and/or weak neck musculature is an SRCs risk factor [38]. Neck strengthening may help prevent SRCs by reducing head acceleration [39, 40]. Support for neck strengthening exists primarily based on anecdotal evidence- and lab-based testing, but not clinical evidence. One such lab study found that every 1-pound increase in neck strength contributes to a 5% decrease in odds for a concussive event to occur [38]. This protective benefit is likely due to the decreased kinematic response of the head to controlled impulsive loading with greater neck strength [39]. It is also believed that neck-strengthening exercises are more likely to reduce SRCs in females than males due to females’ weaker necks [1, 38, 41,42,43,44]. Multiple neck strengthening programs have been proposed that show promise [39, 45]. However, further research is required on the benefit of neck strengthening on concussion prevention during actual play.
Rule Changes
Question: How effective have rule changes been in reducing the number of concussions? Is there a difference in the effectiveness from sport to sport?
Rule changes intended to reduce collisions that often result in concussion have been proposed and implemented in several sports. The difficulty in coming up with new rules is finding a balance between limiting the number of head collisions while maintaining the game’s integrity. Additionally, rule changes in specific sports cannot be generally applied across all levels of play from youth to the elite level.
Football
Football has implemented several safety-related rule changes in an effort to reduce SRCs and other injuries. In 2011, the NFL moved the kickoff line forward by 5 yards in an attempt to prevent concussions. That rule change was intended to increase rates of touchbacks on kickoffs, a play involving high-speed collisions in which a disproportionate number of SRCs have been found to occur. In 2016, the Ivy League, a Division I National Collegiate Athletic Association conference, moved the kickoff and touchback lines up to the 40-yard and 25-yard lines, respectively, for the same reasons. A 2018 study found these rule changes reduce the average annual concussion rate in Ivy League football by more than 68% [46].
Certain youth football leagues have postponed tackling until a certain age and/or reduced the number of contact practices [47].The NFL also adopted a rule beginning in the 2018–2019 season making it a foul for a player to lower his head to initiate and make contact with his helmet against an opponent [48].
Hockey
Body checking and fighting, which are associated with higher risk of SRCs, are hot button, safety-related issues debated in hockey. Until the 2010–2011 season, a body check to an opponent’s head as the primary point of contact was legal in the National Hockey League (“NHL”). Beginning that season, in an effort to prevent SRCs and other head injuries, the NHL adopted Rule 48.1, which made targeting an opponent’s head from the blind side illegal. An independent study released in July 2013 found no decrease in concussion incidence among NHL players following implementation of Rule 48 [49].Footnote 1
Removing body checking at the youth level has also gained popularity [37]. Since 2011, USA Hockey, the American youth hockey governing board, has prohibited all body checking in players 12 and younger [37]. In Canada, the age at which body checking is allowed has also increased to 13 years old [37]. A 2011 Canadian study found that eliminating body checking under age 13 lead to significant reduction in SRCs among youth 13 and under compared to SRCs among similarly aged youth playing in leagues that allowed checking [50]. Opponents of the youth body checking ban were concerned that such a ban would increase the risk of injury, including SRCs, to young players by depriving them of the chance to learn proper body checking technique once they grew and joined leagues in which body checking is permissible. The authors of this chapter are not aware of any research that substantiates this concern and the same 2011 Canadian study specifically refuted it [37, 50]. Disallowing body checking has also been incorporated into older age groups in non-elite levels, but the impact on concussions in these groups requires further investigation [51].
In an effort to reduce fighting, beginning the 2016–17 season, the American Hockey League adopted Rule 23.7, which provides an automatic one-game suspension after a player incurs ten fighting major penalties during the regular season [52]. The Ontario Hockey League adopted a similar rule in 2011 [53].
Other Sports
Other sports have also instituted rule changes in an effort to reduce SRCs. For example, since 2014, Major League Baseball has banned avoidable collisions between catchers and base runners at home plate by initiating a rule that disallows runners attempting to score from deviating from his direct pathway to the plate [54]. In 2015, US Soccer, the soccer governing body in the United States, banned heading among players younger than age 10 and limited the amount of heading in practice among players ages 11–13 [55, 56].
Rule Enforcement
Question: How effective have rule changes been in reducing illegal play?
While the rules of play form the basis of safer play, athletes, coaches, and officials need to adhere to the rules in order for them to make a difference [37]. In high school athletes, illegal activity contributed to over 10% of injuries in boys and girls soccer and basketball, and concussions made up the greatest percentage of those injuries [57]. The injuries related to illegal play are even greater in other leagues and have been reported to be as high as 50% [57, 58]. Promoting fair and safer play requires an attitude shift and modeling by coaches, parents, officials, and managers in addition to the athletes. In ice hockey, fair play rules, a program developed to reward teams with good sportsmanship, has contributed to a significant reduction in injuries including concussions [37]. Additionally, the zero tolerance to head contact rule change in the NHL has led to a 36% reduction in concussion risk [49]. In soccer, stricter enforcement of red cards for high elbows during heading duals has led to a slightly reduced risk of concussion [3, 59].
Legislation
Question: Have states implemented legislation to protect children from SRCs?
Is medical clearance needed prior to returning to sports following a concussion?
Concussion management in youth sports is subject to a state-by-state patchwork of laws and regulations [60, 61]. The most well-known of these laws is Washington State’s Lystedt Law [62]. The Lystedt Law was enacted in 2009 in the aftermath of the tragic death of Zackery Lystedt who suffered multiple concussions in a single game resulting in intracranial hemorrhage and severe traumatic brain injury. The Lystedt Law has three main components: (1) removal; (2) medical clearance for return-to-play; and (3) education [60, 62]. Since the Lystedt Law’s enactment, all 50 states have enacted some form of legislation to protect children from SRCs. Many of these are patterned on the Lystedt Law but significant differences exist.
Several studies have looked at the impact of the Lystedt Law in Washington State and similar laws in other states on concussions in high school athletes [61, 63,64,65]. Studies have found an increase both in the frequency of concussions and the mean number of days during which concussed youths are held out of play. This is likely due to the increased awareness of concussions in addition to the need for medical clearance prior to returning to play. In regards to implementation, high school football and soccer coaches in Washington State endorsed receiving appropriate concussion education 3-years after the Lystedt Law was passed [66]. However, there is still a lot that must be done to in regards to implementation of the laws [61, 63]. One study found that after enacting a concussion law in Ohio the rate of follow-up after an initial ED visit for concussion increased from 44% pre-law to 58% post-law, which means that nearly 40% of concussed players did not receive appropriate follow-up and therefore clearance [61, 64].
Education
Question: Do formal concussion education programs improve concussion knowledge? Does education decrease the rate of concussions?
Several formal education programs have been established that focus on both primary and secondary prevention strategies with specific information geared towards the athletes, coaches/staff, parents, healthcare providers, and/or the public. There is consensus among policies, guidelines, and consensus statements on school sport injury prevention that education is the mainstay of concussion prevention [24]. A large component of programs is teaching improved identification and reporting of concussions to protect against athletes the potential consequences of playing with concussions. Most also emphasize strict adherence to return to play guidelines (refer to chapter on return to play). Programs also aim to educate on the short and long-term consequences of suffering a concussion with the hope of changing attitudes on the playing field to prevent risky behaviors that may lead to concussions. While several educational programs have been developed and most show increased rates of concussion knowledge after the programs, further research into whether they actually decrease the rates of concussions is required. The specific education method or program should be tailored to each individual group to optimize learning. Table 12.1 lists several education programs and resources that currently exist.
The annual pre-participation physical exam (PPE) can be very useful in identifying athletes who have a history of concussion and who may be at increased risk for concussion due to involvement in contact sports. The PPE provides an excellent educative opportunity to inform athletes and their parents of the significance of concussions [51]. The medical professional performing the exam should ask concussion-related questions including past history of concussion, duration of symptoms, and the presence of mood, learning attention, or migraine disorders, which have been shown to complicate the diagnosis and management of concussed athletes [1]. However, there is no evidence that pre-existing mood or learning disorders predisposes athletes to concussions.
Conclusion
Researchers have made considerable progress over the past 20 or so years in determining the causes of SRCs but have made fewer inroads in determining how to prevent them. There is no cure-all to prevent SRCs. This much is known.
Nevertheless, much of the existing research is imprecise and/or unsatisfying and questions abound. More research is required, and until such research becomes available, PCPs are left to endorse SRC prevention strategies based largely on intuition and anecdotal evidence.
Key Points
-
Investigating the effect of helmets to reduce SRC has proven to be challenging and requires on-going research.
-
Teaching proper technique in sports activities such as sport-specific techniques to reduce head acceleration may help to reduce concussions.
-
Rule changes intended to reduce collisions that often result in concussion have been proposed and implemented in several sports.
-
More research is required and until such research becomes available, PCPs are left to endorse SRC prevention strategies based largely on intuition and anecdotal evidence.
Notes
- 1.
Rule 48 has been revised several times since the 2010–2011 and season and currently to define an illegal check to the head as “a hit resulting in contact with an opponent’s head where the head was the main point of contact and such contact to the head was avoidable.” http://www.nhl.com/nhl/en/v3/ext/rules/2018-2019-NHL-rulebook.pdf; https://www.cbc.ca/sports-content/hockey/opinion/ 2013/09/30-thoughts-nhl-clarifies-illegal-check-to-head-rule.htm
References
Harmon KG, Drezner JA, Gammons M, et al. American medical society for sports medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15–26.
Zuckerman SL, Reynolds BB, Yengo-Kahn AM, et al. A football helmet prototype that reduces linear and rotational acceleration with the addition of an outer shell. J Neurosurg. 2018:1–8. https://doi.org/10.3171/2018.1.JNS172733.
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):978–84.
Schneider DK, Grandhi RK, Bansal P, et al. Current state of concussion prevention strategies: a systematic review and meta-analysis of prospective, controlled studies. Br J Sports Med. 2017;51(20):1473–82.
Nfl, nflpa release 2019 helmet laboratory testing performance results. States News Service. Apr 12, 2019.
McGuine TA, Hetzel S, McCrea M, Brooks MA. Protective equipment and player characteristics associated with the incidence of sport-related concussion in high school football players. Am J Sports Med. 2014;42(10):2470–8.
Haider AH, Saleem T, Bilaniuk JW, Barraco RD. An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders. J Trauma Acute Care Surg. 2012;73(5):1340–7.
Hagel BE, Pless IB, Goulet C, Platt RW, Robitaille Y. Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study. BMJ. 2005;330(7486):281–3.
Rowson S, Duma SM, Greenwald RM, et al. Can helmet design reduce the risk of concussion in football? J Neurosurg. 2014;120(4):919–22.
Bland ML, Zuby DS, Mueller BC, Rowson S. Differences in the protective capabilities of bicycle helmets in real-world and standard-specified impact scenarios. Traffic Inj Prev. 2018;19(sup1):S163.
Bland ML, McNally C, Rowson S. Differences in impact performance of bicycle helmets during oblique impacts. J Biomech Eng. 2018;140(9):91005.
Delaney JS, Al-Kashmiri A, Drummond R, Correa JA. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. Br J Sports Med. 2008;42(2):5; discussion 115.
Barnes A, Rumbold JL, Olusoga P. Attitudes towards protective headgear in UK rugby union players. BMJ Open Sport Exerc Med. 2017;3(1):e000255.
Ganly M, McMahon JM. New generation of headgear for rugby: impact reduction of linear and rotational forces by a viscoelastic material-based rugby head guard. BMJ Open Sport Exerc Med. 2018;4(1):e000464.
Harmon KG, Clugston JR, Dec K, et al. American medical society for sports medicine position statement on concussion in sport. Br J Sports Med. 2019;53(4):213–25.
Halstead ME, Walter KD, Moffatt K. Sport-related concussion in children and adolescents. Pediatrics. 2018;142(6):1.
Greenhill DA, Navo P, Zhao H, Torg J, Comstock RD, Boden BP. Inadequate helmet fit increases concussion severity in american high school football players. Sports Health. 2016;8(3):238–43.
Centers for Disease Control and Prevention. CDC HEADS UP concussion and helmet safety.
Taylor K. The cost of high school football — dollars must be stretched to train, equip, feed teams. The Gadsden Times. 08/17/2016. https://www.gadsdentimes.com/news/20160817/cost-of-high-school-football%2D%2D-dollars-must-be-stretched-to-train-equip-feed-teams. Accessed 27 Sept 2019.
VICIS I. VICIS announces price reduction of ZERO1 helmet. PR Newswire. Jan 18, 2018. Available from: https://search.proquest.com/docview/1988489058.
Good sports. https://www.goodsports.org/about/. Accessed 27 Sept 2019.
Sports matter: Help save youth sports. https://www.sportsmatter.org. Accessed 27 Sept 2019.
The sports shed. https://thesportsshed.org. Accessed 27 Sept 2019.
Göpfert A, Van Hove M, Emond A, Mytton J. Prevention of sports injuries in children at school: a systematic review of policies. BMJ Open Sport Exerc Med. 2018;4(1):e000346.
Waldstein D. Safer batting helmet draws resistance from some players. New York Times. August 12, 2009:B11. https://www.nytimes.com/2009/08/13/sports/baseball/13helmet.html. Accessed 27 Sept 2019.
Mark Maske. NFL players, including tom brady, will have to be in approved helmets this season. https://search.proquest.com/docview/2208587151. Updated 2019.
Brophy M. NHL, NHLPA agree on mandatory visors https://www.nhl.com/news/nhl-nhlpa-agree-on-mandatory-visors/c-672983. Accessed 27 Sept 2019.
Kerr ZY, Yeargin S, Valovich McLeod TC, et al. Comprehensive coach education and practice contact restriction guidelines result in lower injury rates in youth american football. Orthop J Sports Med. 2015;3(7):2325967115594578.
Kerr ZY, Dalton SL, Roos KG, Djoko A, Phelps J, Dompier TP. Comparison of Indiana high school football injury rates by inclusion of the USA football “heads up football” player safety coach. Orthop J Sports Med. 2016;4(5):2325967116648441.
USA Football. Heads up football. https://usafootball.com/programs/heads-up-football/. Accessed 27 Sept 2019.
Schussler E, Jagacinski RJ, White SE, Chaudhari AM, Buford JA, Onate JA. The effect of tackling training on head accelerations in youth american football. Int J Sports Phys Ther. 2018;13(2):229–37.
ALAN SCHWARZ. N.F.L.-backed youth program says it reduced concussions. the data disagrees. https://search.proquest.com/docview/1807059662. Updated 2016.
Hallenbeck S. USA football statement on New York times article about heads up football. 2016.
Shanley E, Thigpen C, Kissenberth M, Gilliland RG, Thorpe J, Nance D, Register-Mihalik JK, Tokish J. Heads up football training decreases concussion rates in high school football players. Clin J Sports Med.:1. https://doi.org/10.1097/jsm.0000000000000711.
Shewchenko N, Withnall C, Keown M, Gittens R, Dvorak J. Heading in football. Part 3: effect of ball properties on head response. Br J Sports Med. 2005;39(suppl 1):i39.
Caccese J, Kaminski T. Minimizing head acceleration in soccer: a review of the literature. Sports Med. 2016;46(11):1591–604.
Anonymous. Reducing injury risk from body checking in boys’ youth ice hockey. Pediatrics. 2014;133(6):1151–7.
Collins C, Fletcher E, Fields S, et al. Neck strength: a protective factor reducing risk for concussion in high school sports. J Prim Prev. 2014;35(5):309–19.
Eckner JT, Goshtasbi A, Curtis K, et al. Feasibility and effect of cervical resistance training on head kinematics in youth athletes: a pilot study. Am J Phys Med Rehabil. 2018;97(4):292–7.
Tierney RT, Higgins M, Caswell SV, et al. Sex differences in head acceleration during heading while wearing soccer headgear. J Athl Train. 2008;43(6):578–84.
Benson BW, Gunter FE, Rauch R, et al. What are the most effective risk-reduction strategies in sport concussion? J Med Genet. 2013;47(5):321.
Tierney RT, Sitler MR, Swanik CB, Swanik KA, Higgins M, Torg J. Gender differences in head-neck segment dynamics stabilization during head acceleration. Med Sci Sports Exerc. 2005;37(2):272–9.
Mansell J, Tierney RT, Sitler MR, Swanik KA, Stearne D. Resistance training and head-neck segment dynamic stabilization in male and female collegiate soccer players. J Athl Train. 2005;40(4):310–9.
Hildenbrand K, Vasavada A. Collegiate and high school athlete neck strength in neutral and rotated postures. J Strength Cond Res. 2013;27(11):3173–82.
Toninato JC, Casey H, Uppal M, Abdallah T, Bergman T, Eckner JT, Samadani U. Traumatic brain injury reduction in athletes by neck strengthening (TRAIN). Contemp Clin Trials Commun. 2018;11:102–6.
Wiebe DJ, D’Alonzo BA, Harris R, Putukian M, Campbell-McGovern C. Association between the experimental kickoff rule and concussion rates in ivy league football. JAMA. 2018;320(19):2035–6.
Pop Warner. Limited contact in practice rule. https://tshq.bluesombrero.com/Default.aspx?tabid=1476228. Accessed 27 Sept 2019.
Use of the helmet – rule 12, section 2, article 8. https://nflcommunications.com/Documents/Fact%20Sheet%20-%20Use%20of%20the%20Helmet.pdf. Accessed 27 Sept 2019.
Donaldson L, Asbridge M, Cusimano MD. Bodychecking rules and concussion in elite hockey. PLoS One. 2013;8(7):e69122.
Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. CMAJ. 2011;183(11):1249–56.
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):838–47.
American hockey league official rule book 2018–2019. https://theahl.com/rules. Accessed 27 Sept 2019.
OHL announces player safety initiatives and rule changes for 2016–17 season. http://ontariohockeyleague.com/article/ohl-announces-player-safety-initiatives-and-rule-changes-for-2016-17-season. Updated 2019. Accessed 4 May 2019.
2019 Official baseball rules. https://content.mlb.com/documents/2/2/4/305750224/2019_Official_Baseball_Rules_FINAL_.pdf. Accessed 27 Sept 2019.
U.S. soccer concussion guidelines. https://www.recognizetorecover.org/head-and-brain#concussions. Accessed 27 Sept 2019.
Player safety campaign FAQs - US soccer; https://www.ussoccer.com/about/recognize-to-recover/concussion-guidelines/player-safety-campaign-faqs.
Collins CL, Fields SK, Comstock RD. When the rules of the game are broken: what proportion of high school sports-related injuries are related to illegal activity? Inj Prev. 2008;14(1):34–8.
Junge A, Dvorak J, Graf-Baumann T, Peterson L. Football injuries during FIFA tournaments and the olympic games, 1998-2001. Am J Sports Med. 2004;32(1_suppl):80–9.
Bjørneboe J, Bahr R, Dvorak J, Andersen TE. Lower incidence of arm-to-head contact incidents with stricter interpretation of the laws of the game in norwegian male professional football. Br J Sports Med. 2013;47(8):508–14.
Spaude LK. Time to act: correcting the inadequacy of youth concussion legislation through a federal act. Marquette Law Rev. 2017;100(3):1093.
Fisher PG. Have zackery lystedt concussion laws made an impact? J Pediatr. 2019;206:2–3.
HB 1824-2009-10. Requiring the adoption of policies for the management of concussion and head injury in youth sports. Sponsors: Rodne, Quall, Anderson, Liias, Walsh, M., Pettigrew, Priest, Simpson, Kessler, Rolfes, Johmson, Sullivan, Morrell.
Davies S, Coxe K, Harvey HH, Singichetti B, Guo J, Yang J. Qualitative evaluation of high school implementation strategies for youth sports concussion laws. J Athl Train. 2018;53(9):873–9.
Tarimala A, Singichetti B, Yi H, et al. Initial emergency department visit and follow-up care for concussions among children with medicaid. J Pediatr. 2019;206:178–83.
Bompadre V, Jinguji TM, Yanez ND, et al. Washington state’s lystedt law in concussion documentation in Seattle public high schools. J Athl Train. 2014;49(4):492.
Chrisman SP, Schiff MA, Chung SK, Herring SA, Rivara FP. Implementation of concussion legislation and extent of concussion education for athletes, parents, and coaches in Washington state. Am J Sports Med. 2014;42(5):1190–6.
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Weber, K.M., Portin, E.B. (2020). Concussion Prevention. In: Patel, D. (eds) Concussion Management for Primary Care . Springer, Cham. https://doi.org/10.1007/978-3-030-39582-7_12
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DOI: https://doi.org/10.1007/978-3-030-39582-7_12
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