The Concussion Blog

There was a recent study released that has turned some heads in regards to where all the concussions come from in sports. In this JAMA Pediatrics study appearing at the beginning of the month the investigators have concluded that American football practices were “a major source of concussions” for all three levels of participation studied (youth, high school and collegiate).

Often when we see this type of information released there can be confusion due to the limitation of each individual study. The above data reflects a single sport, football, as compared to other data often cited that deals with all sports. Case in point this National Institute of Health study; which reports “athletes tend to have a higher risk of concussion in competition as compared to practice.”

The discussion topic of where concussion occurs more is not only often debated but it is an important set of data because we can control for one side of this equation, practice.

Reading the JAMA article one might be confused about the conclusions if you were to look only at the data and not have complete context of both the sport and participation. The rate of concussion was extremely higher in competition versus practice yet the majority of overall concussions came from practice. This can be explained by noting that there are far fewer games – thus exposure – and fewer participants in games – thus exposure. The sample set for the data (JAMA) was fairly robust: 118 youth football teams, 96 secondary school football programs and 24 collegiate programs. Ages of athletes exposed were 5 to 23, presenting a very good cross-section of the sport at all levels it is being played at. This information was collected in 2012 and 2013, and the researchers collected over 1,100 concussions over that time frame.

The NIH study breaks down the information for 13 different sports in high school and college only. Their findings about concussions being more likely and prevalent in competition is easily explained by the fact that most of the sports are not full-contact in practice, thus the likelihood of a concussion, say in volleyball, is very small in practice but likely in games due to effort.

A quick aside looking at some of the comparable data between the two studies; the injury rate ratio (injury per 1000 athlete exposures) for college has increased significantly in both practice and games for college and high school football players. The NIH study reported HS concussions from the 2005-06 season and I can’t seem to identify the year(s) the college concussions were reported in. However the numbers are very telling as time has gone on with reporting and ferreting out the injury:

• NIH College = 0.39 injury rate ratio for practice and 3.02 for games
• JAMA College = 0.53 injury rate ratio for practice and 3.74 for games
• NIH HS = 0.21 injury rate ratio for practice and 1.55 for games
• JAMA HS = 0.80 injury rate ratio for practice and 1.86 for games

Two fold increase in practice concussions for high school football from 2005 to 2013, that is quite telling for many reasons – recognition and education being the biggest reasons.

Back to the reason for the post the debate over the where the most concussions come from…

Logically and linear thinking produces the summation that where there is more exposure to contact/collision, whether it be in football or other sports, there will be more overall concussions. So, this becomes a sport dependent argument and result; in football and hockey where there is more contact in practice because that is a skill that is necessary for playing the sport you will see more concussions in those practices. In soccer or basketball where collision is avoided and not taught there will be less concussions in practice and more in games where collisions are just part of the game action.

This leads us to the hottest topic in concussions and sports, limiting contact in practices – focus is naturally football. Because concussions cannot be attenuated by equipment or behavior modification and are a result of collisions/contact (with others, equipment or surfaces) the only logical way to reduce overall numbers of concussions is to limit exposure.

It is important to remember that as we advance our techniques for identifying concussions and introduce technology to help us objectively monitor impacts we will see numbers rise. This, in my opinion, is not fully due to there being more of them — although as the athlete gets bigger, faster and stronger that is a natural by-product — it is just a result of us being more aware. And as we become more aware of the injury we should also be more aware of ways to limit the chance of one “catching a concussion”, the obvious place is where we can control all aspects, practice.

For what its worth; I have seen more concussions in practice versus games during my tenure as a high school athletic trainer, but it is slowly starting to equal out. This may be due to the coaches I have worked with reducing contact in practices over the past few years.