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Abstract

Objectives: To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and /or head impact risk. 

Design: This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. 

Data sources: Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review. 

Eligibility criteria: Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. 

Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English. 

Results: In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies. 

Conclusions: Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC. PROSPERO registration number CRD42019152982.

Original languageEnglish
Pages (from-to)749-761
Number of pages13
JournalBritish Journal of Sports Medicine
Volume57
Issue number12
Early online date14 Jun 2023
DOIs
Publication statusPublished - 30 Jun 2023

Bibliographical note

Funding Information:
PE: Data consultant to the National Hockey League. Received an honorarium for the administrative aspects of the concussion consensus review. JMG: No conflicts of interest. ATK: Research funding for PhD received from Canadian Institutes of Health Research and University of Calgary Eyes High Doctoral Recruitment Scholarship. Youth Council Member for the Canadian Institutes of Health Research Institute of Human Development, Child, and Youth Health’s. MPP: No conflicts of interest. SWW: Research funding received from World Rugby. SBailey: PhD Research was funded by Scottish Rugby, the national governing body for rugby union in Scotland. LM: No conflicts of interest. AMB: Peer-reviewed research funding from the Social Sciences and Humanities Research Council, Sport Information Resource Center board member, Canadian Athletic Therapists Association committee member. Received an honorarium for the administrative aspects of the concussion consensus reviews. SBroglio: Research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense-USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex and EA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medicolegal litigation, and received speaker honorarium and travel reimbursements for talks given. He is coauthor of 'Biomechanics of Injury (3rd edition)' and has a patent pending on 'Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source' (US Application No. 17/164490). He is on the and is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present), British Journal of Sports Medicine (2008 to 2019). GAD: Member of the Scientific Committee of the 6th International Consensus Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF and FIFA; however, has not received any payment, research funding, or other monies from these groups other than for travel costs. BEH: No conflicts of interest. JDS: No conflicts of interest. KAS: Employed (part-time) by the Rugby Football Union, the national governing body for rugby union in England. Research funding received from World Rugby, Rugby Football Union, Premiership Rugby, Football Association Premier League, England and Wales Cricket Board, and British Racing Foundation. MT: No conflicts of interest. RT: Employed as a consultant by World Rugby, the body that regulates the sport of Rugby Union globally. The role includes research into prevention of concussion through various interventions. NW: International Paralympic Committee Medical Committee. RZ: Current or past competitively funded research grants from Canadian Institutes of Health Research (CIHR), National Institutes of Health (NIH), Health Canada, Ontario Neurotrauma Foundation (ONF), Ontario Ministry of Health, Physician Services Incorporated (PSI) Foundation, CHEO Foundation, University of Ottawa Brain and Mind Research Institute, Ontario Brain Institute (OBI), and Ontario SPOR Support Unit (OSSU), and the National Football League (NFL) Scientific Advisory Board. I hold Clinical Research Chair in Pediatric Concussion from University of Ottawa, and I am on the concussion advisory board for Parachute Canada (a non-profit injury prevention charity). I am the cofounder, Scientific Director, and a minority shareholder in 360 Concussion Care (an interdisciplinary concussion clinic). AH: No conflicts of interest. KAS: Kathryn Schneider has received grant funding from the Canadian Institutes of Health Research, National Football League Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary) with funds paid to her institution and not to her personally. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is coordinating the writing of the systematic reviews that will inform the 6th International Consensus on Concussion in Sport, for which she has received an educational grant to assist with the administrative costs associated with the writing of the reviews. She is a member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid positions). CE: Carolyn Emery has received external peer-reviewed research funding from Canadian Institutes of Health Research, Canada Foundation for Innovation, International Olympic Committee Medical and Scientific Committee, National Football League Play Smart Play Safe Program, and World Rugby. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is an external advisory board member for HitIQ.

Data Availability Statement

All data relevant to the study are included in the
article or uploaded as online supplemental information.

Keywords

  • Brain Concussion
  • Preventive Medicine
  • Risk factor
  • Sport

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation
  • Orthopedics and Sports Medicine

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