Prevention strategies and modifiable risk factors for concussion: a systematic review and meta-analysis for the Female, woman and girl Athlete Injury pRevention (FAIR) consensus.
Shill, Isla J; Shepherd, Heather A; Eliason, Paul Het al.
2025 • In British Journal of Sports Medicine, p. 2025-109915
Brain Concussion; Female; Risk factor; Women in sport
Abstract :
[en] [en] OBJECTIVE: To examine prevention strategies and potential modifiable risk factors (MRFs) for sport-related concussion (SRC) and head impact/head acceleration event (HAE) outcomes in female, woman and/or girl athletes.
DESIGN: Systematic review with meta-analyses and Grading of Recommendations, Assessment, Development and Evaluation.
DATA SOURCES: Medline, CINAHL, PsycINfo, SportDiscus, ERIC, CENTRAL and CDSR.
ELIGIBILITY: Primary data studies with comparison group(s) assessing the association of prevention interventions and/or MRFs for SRC or HAE with ≥1 female/woman/girl in each study group.
RESULTS: Of the 108 included studies, 67 evaluated a SRC prevention strategy (equipment n=25, policy/rule n=21, training n=10, management n=11) and 41 evaluated potential MRFs (34 distinct MRFs across nine categories). In total, 40/108 (37%) studies (prevention 19/67; MRF 21/41) included female/woman/girl-specific estimates. Three meta-analyses were conducted: two SRC prevention strategies (headgear, eyewear) and one MRF (artificial turf vs grass) based on availability of female/woman/girl-only estimates and similar outcomes and exposure. Headgear was associated with 30% lower SRC rates in adolescent female/girl lacrosse and soccer (IRR=0.70, 95% CI 0.50 to 0.99; very-low certainty). Eyewear use was not protective for SRC (IRR=1.08, 95% CI 0.69 to 1.68; very-low certainty). SRC rates did not differ by artificial turf versus grass (IRR=0.95, 95% CI 0.62 to 1.45; very-low certainty).
CONCLUSION: We found limited evidence for prevention strategies and MRFs in female/woman/girl athletes except for very-low certainty evidence supporting headgear use in adolescent lacrosse and soccer. Future studies should consider the design, implementation and evaluation of SRC prevention strategies that target MRFs to guide safe practice recommendations specifically for female/woman/girl athletes.
Disciplines :
Orthopedics, rehabilitation & sports medicine
Author, co-author :
Shill, Isla J ; Edinburgh Sports Medicine Research Centre, Institute for Sport, PE and Health Sciences, University of Edinburgh, Edinburgh, UK ; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada ; UK Collaborating Centre on Injury and Illness Prevention in Sport, Universities of Edinburgh and Bath, Edinburgh and Bath, UK
Shepherd, Heather A ; Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
Eliason, Paul H ; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
Kolstad, Ash T ; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
Heyward, Omar ; Carnegie School of Sport, Leeds Beckett University, Leeds, UK ; Rugby Football Union, Twickenham, UK
Martens, Géraldine ; Université de Liège - ULiège > Département des Sciences de l'activité physique et de la réadaptation
Peek, Kerry ; FIFA Medical, Fédération Internationale de Football Association, Zurich, Switzerland ; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
Soligon, Clara A ; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
King, Matthew G ; Discipline of Physiotherapy, La Trobe University, Bundoora, Victoria, Australia
West, Stephen W; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada ; UK Collaborating Centre on Injury and Illness Prevention in Sport, Universities of Edinburgh of Bath, Edinburgh and Bath, UK ; Centre for Health, and Injury & Illness Prevention in Sport, University of Bath, Bath, UK
Ahmed, Osman Hassan ; The Football Association, Burton-upon-Trent, UK ; University Hospitals Dorset NHS Foundation Trust, Poole, UK ; School of Psychology, Sport and Health Sciences, University of Portsmouth, Portsmouth, UK
Blauwet, Cheri A; Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, Massachusetts, USA
Broglio, Steven ; University of Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
Chintoh, Araba ; Dept. of Psychiatry, University of Calgary, Calgary, Alberta, Canada ; Centre for Sport Leadership, Maties Sport, Stellenbosch University, Stellenbosch, South Africa
Galarneau, Jean-Michel ; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
Hayden, K Alix ; Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
Hendricks, Sharief ; Carnegie School of Sport, Leeds Beckett University, Leeds, UK ; Division of Physiological Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
Makdissi, Michael ; Australian Football League, Melbourne, Victoria, Australia ; La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
Palmer, Debbie ; Edinburgh Sports Medicine Research Centre, Institute for Sport, PE and Health Sciences, University of Edinburgh, Edinburgh, UK ; UK Collaborating Centre on Injury and Illness Prevention in Sport, Universities of Edinburgh and Bath, Edinburgh and Bath, UK
Sick, Stacy; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
Whittaker, Jackie L ; Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada ; Arthritis Research Canada, Vancouver, British Columbia, Canada
Crossley, Kay M ; La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
Schneider, Kathryn J ; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
Emery, Carolyn A ; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada caemery@ucalgary.ca
Prevention strategies and modifiable risk factors for concussion: a systematic review and meta-analysis for the Female, woman and girl Athlete Injury pRevention (FAIR) consensus.
McGroarty NK, Brown SM, Mulcahey MK. Sport-Related Concussion in Female Athletes: A Systematic Review. Orthop J Sports Med 2020;8:2325967120932306. doi:10.1177/2325967120932306
Covassin T, Moran R, Elbin RJ. Sex Differences in Reported Concussion Injury Rates and Time Loss From Participation: An Update of the National Collegiate Athletic Association Injury Surveillance Program From 2004-2005 Through 2008-2009. J Athl Train 2016;51:189–94. doi:10.4085/1062-6050-51.3.05
Shill IJ, West SW, Sick S, et al. Differences in injury and concussion rates in a cohort of Canadian female and male youth Rugby Union: a step towards targeted prevention strategies. Br J Sports Med 2024;58:34–41. doi:10.1136/bjsports-2023-106929
Resch JE, Rach A, Walton S, et al. Sport Concussion and the Female Athlete. Clin Sports Med 2017;36:717–39. doi:10.1016/j.csm.2017.05.002
Covassin T, Elbin RJ. The female athlete: the role of gender in the assessment and management of sport-related concussion. Clin Sports Med 2011;30:125–31,. doi:10.1016/j.csm.2010.08.001
Williams EMP, Petrie FJ, Pennington TN, et al. Sex differences in neck strength and head impact kinematics in university rugby union players. Eur J Sport Sci 2022;22:1649–58. doi:10.1080/17461391.2021.1973573
Caccese JB, Lamond LC, Buckley TA, et al. Reducing purposeful headers from goal kicks and punts may reduce cumulative exposure to head acceleration. Res Sports Med 2016;24:407–15. doi:10.1080/15438627.2016.1230549
McLeod S, Tucker R, Edwards S, et al. A case-control study of tackle based head impact event (HIE) risk factors from the first three seasons of the National Rugby League Women’s competition. Front Sports Act Living 2023;5:1080356. doi:10.3389/fspor.2023.1080356
Emery CA, Pasanen K. Current trends in sport injury prevention. Best Pract Res Clin Rheumatol 2019;33:3–15. doi:10.1016/j.berh.2019.02.009
Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med 2022;57:695–711.
Schneider KJ, Emery CA, Black A, et al. Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment. J Orthop Sports Phys Ther 2019;49:799–810. doi:10.2519/jospt.2019.8926
Meeuwisse WH, Tyreman H, Hagel B, et al. A dynamic model of etiology in sport injury: the recursive nature of risk and causation. Clin J Sport Med 2007;17:215–9. doi:10.1097/JSM.0b013e3180592a48
Eliason PH, Galarneau J-M, Kolstad AT, et al. Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis. Br J Sports Med 2023;57:749–61. doi:10.1136/bjsports-2022-106656
National Football League Football Operations. More girls are playing tackle football. 2020. Available: https://operations.nfl.com/gameday/analytics/stats-articles/more-girls-are-playing-tackle-football/#:~:text=Playing%20Tackle%20Football-,January%209%2C%202020,girls%20participation%20continues%20to%20grow
Women’s football alliance. 2025 Available: https://wfaprofootball.com
World Rugby. Year in review. Dublin, Ireland, 2021.
Australian Football League. 2023 annual report. 2023.
Higgins JPT, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions. 2nd edn. John Wiley & Sons, 2019.
Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. J Clin Epidemiol 2021;134:178–89. doi:10.1016/j.jclinepi.2021.03.001
Rethlefsen ML, Kirtley S, Waffenschmidt S, et al. PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews. Syst Rev 2021;10:39. doi:10.1186/s13643-020-01542-z
Veritas Health Innovation. Covidence systematic review software. Melbourne, Australia,
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377–84. doi:10.1136/jech.52.6.377
StataCorp. Stata statistical software: release 18. college station, tx: statacorp llc. 2023.
Huguet A, Hayden JA, Stinson J, et al. Judging the quality of evidence in reviews of prognostic factor research: adapting the GRADE framework. Syst Rev 2013;2:71. doi:10.1186/2046-4053-2-71
Antonoff DG, Goss J, Langevin TL, et al. Unexpected Findings from a Pilot Study on Vision Training as a Potential Intervention to Reduce Subconcussive Head Impacts during a Collegiate Ice Hockey Season. J Neurotrauma 2021;38:1783–90. doi:10.1089/neu.2020.7397
Howell DR, Seehusen CN, Carry PM, et al. An 8-Week Neuromuscular Training Program After Concussion Reduces 1-Year Subsequent Injury Risk: A Randomized Clinical Trial. Am J Sports Med 2022;50:1120–9. doi:10.1177/03635465211069372
Mansell J, Tierney RT, Sitler MR, et al. Resistance training and head-neck segment dynamic stabilization in male and female collegiate soccer players. J Athl Train 2005;40:310–9.
Morrissey S, Dumire R, Causer T, et al. The missing piece of the concussion discussion: primary prevention of mild traumatic brain injury in student athletes. J Emerg Crit Care Med 2019;3:8. doi:10.21037/jeccm.2019.01.06
Müller C, Zentgraf K. Neck and Trunk Strength Training to Mitigate Head Acceleration in Youth Soccer Players. J Strength Cond Res 2021;35:S81–9. doi:10.1519/JSC.0000000000003822
Peek K, Andersen J, McKay MJ, et al. The Effect of the FIFA 11+with Added Neck Exercises on Maximal Isometric Neck Strength and Peak Head Impact Magnitude During Heading: A Pilot Study. Sports Med 2022;52:655–68. doi:10.1007/s40279-021-01564-0
Peek K, Versteegh T, Veith S, et al. Injury-Reduction Programs Containing Neuromuscular Neck Exercises and the Incidence of Soccer-Related Head and Neck Injuries. J Athl Train 2023;58:519–27. doi:10.4085/1062-6050-0340.22
Wahlquist VE, Glutting JJ, Kaminski TW. Examining the influence of the Get aHEAD Safely in Soccer TM program on head impact kinematics and neck strength in female youth soccer players. Res Sports Med 2024;32:17–27. doi:10.1080/15438627.2022.2079982
Wahlquist VE, Kaminski TW. Analysis of Head Impact Biomechanics in Youth Female Soccer Players Following the Get aHEAD Safely in Soccer TM Heading Intervention. Sensors (Basel) 2021;21:3859. doi:10.3390/s21113859
Waring KM, Smith ER, Austin GP, et al. Exploring the Effects of a Neck Strengthening Program on Purposeful Soccer Heading Biomechanics and Neurocognition. Int J Sports Phys Ther 2022;17:1043–52. doi:10.26603/001c.38327
Black AM, Hagel BE, Palacios-Derflingher L, et al. The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada’s national body checking policy change. Br J Sports Med 2017;51:1767–72. doi:10.1136/bjsports-2016-097392
Black AM, Macpherson AK, Hagel BE, et al. Policy change eliminating body checking in non-elite ice hockey leads to a threefold reduction in injury and concussion risk in 11- and 12-year-old players. Br J Sports Med 2016;50:55–61. doi:10.1136/bjsports-2015-095103
Eliason P, Galarneau J-M, Shill I, et al. Factors Associated With Concussion Rates in Youth Ice Hockey Players: Data From the Largest Longitudinal Cohort Study in Canadian Youth Ice Hockey. Clin J Sport Med 2023;33:497–504. doi:10.1097/JSM.0000000000001177
Eliason P, Galarneau J-M, Schneider K, et al. Higher hazard of concussion combined with recurrent concussion in female youth ice hockey compared with males: An opportunity for concussion prevention. Sports Orthopaedics and Traumatology 2023;39:113–23. doi:10.1016/j.orthtr.2023.04.005
Eliason P, Hagel BE, Palacios-Derflingher L, et al. No association found between body checking experience and injury or concussion rates in adolescent ice hockey players. Br J Sports Med 2022;56:1337–44. doi:10.1136/bjsports-2021-104691
Eliason PH, Hagel BE, Palacios-Derflingher L, et al. Bodychecking experience and rates of injury among ice hockey players aged 15-17 years. CMAJ 2022;194:E834–42. doi:10.1503/cmaj.211718
Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. Can Med Assoc J 2011;183:1249–56. doi:10.1503/cmaj.101540
Emery C, Palacios-Derflingher L, Black AM, et al. Does disallowing body checking in non-elite 13- to 14-year-old ice hockey leagues reduce rates of injury and concussion? A cohort study in two Canadian provinces. Br J Sports Med 2020;54:414–20. doi:10.1136/bjsports-2019-101092
Emery CA, Eliason P, Warriyar V, et al. Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents. Br J Sports Med 2022;56:12–7. doi:10.1136/bjsports-2020-103757
Emery CA, Kang J, Schneider KJ, et al. Risk of injury and concussion associated with team performance and penalty minutes in competitive youth ice hockey. Br J Sports Med 2011;45:1289–93. doi:10.1136/bjsports-2011-090538
Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA 2010;303:2265–72. doi:10.1001/jama.2010.755
Hagel BE, Marko J, Dryden D, et al. Effect of bodychecking on injury rates among minor ice hockey players. CMAJ 2006;175:155–60. doi:10.1503/cmaj.051531
Jae-Ok K, Voaklander D. Effects of Competition Rule Changes on the Incidence of Head Kicks and Possible Concussions in Taekwondo. Clin J Sport Med 2016;26:239–44. doi:10.1097/JSM.0000000000000244
Kolstad AT, Nadeau L, Eliason PH, et al. Does disallowing body checking impact offensive performance in non-elite under-15 and under-18 youth ice hockey leagues? A video-analysis study. Int J Sports Sci Coach 2022.
Lalji R, Snider H, Chow N, et al. The 2015 U.S. Soccer Federation header ban and its effect on emergency room concussion rates in soccer players aged 10-13. J Can Chiropr Assoc 2020;64:187–92.
Macan J, Bundalo-Vrbanac D, Romić G. Effects of the new karate rules on the incidence and distribution of injuries. Br J Sports Med 2006;40:326–30;. doi:10.1136/bjsm.2005.022459
Nadkarni L, Haskins A, Holt C, et al. Reduction of High School Ice Hockey Injuries With Implementation of New Checking/Boarding Rules. Clin J Sport Med 2021;31:e420–4. doi:10.1097/JSM.0000000000000846
Obana KK, Mueller JD, Saltzman BM, et al. Targeting Rule Implementation Decreases Concussions in High School Football: A National Concussion Surveillance Study. Orthop J Sports Med 2021;9:23259671211031191. doi:10.1177/23259671211031191
Smith AM, Gaz DV, Larson D, et al. Does fair play reduce concussions? A prospective, comparative analysis of competitive youth hockey tournaments. BMJ Open Sport Exerc Med 2016;2:e000074. doi:10.1136/bmjsem-2015-000074
Williamson RA, Kolstad AT, Krolikowski M, et al. Incidence of Head Contacts, Penalties, and Player Contact Behaviors in Youth Ice Hockey: Evaluating the “Zero Tolerance for Head Contact” Policy Change. Orthop J Sports Med 2021;9:2325967121992375. doi:10.1177/2325967121992375
Williamson RA, Kolstad AT, Nadeau L, et al. Does Increasing the Severity of Penalties Assessed in Association With the "Zero Tolerance for Head Contact" Policy Translate to a Reduction in Head Impact Rates in Youth Ice Hockey?. Clin J Sport Med 2022;32:e598–604.
Barbic D, Pater J, Brison RJ. Comparison of mouth guard designs and concussion prevention in contact sports: a multicenter randomized controlled trial. Clin J Sport Med 2005;15:294–8. doi:10.1097/01.jsm.0000171883.74056.21
Baron SL, Veasley SJ, Kingery MT, et al. Decreased Injury Rate Following Mandated Headgear Use in Women’s Lacrosse. Bull Hosp Jt Dis (2013) 2013;78:260–5.
Castellanos J, Phoo CP, Eckner JT, et al. Predicting Risk of Sport-Related Concussion in Collegiate Athletes and Military Cadets: A Machine Learning Approach Using Baseline Data from the CARE Consortium Study. Sports Med 2021;51:567–79. doi:10.1007/s40279-020-01390-w
Caswell SV, Kelshaw PM, Lincoln AE, et al. The Effects of Headgear in High School Girls’ Lacrosse. Orthop J Sports Med 2020;8.
Chisholm DA, Black AM, Palacios-Derflingher L, et al. Mouthguard use in youth ice hockey and the risk of concussion: nested case-control study of 315 cases. Br J Sports Med 2020;54:866–70.
Delaney JS, Al-Kashmiri A, Drummond R, et al. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. Br J Sports Med 2008;42:110–5.
Filbay SR, Bullock GS, Sanchez-Santos MT, et al. A Higher Playing Standard, Bowling, and Intermittent Helmet Use Are Related to a Greater Odds of Injury or Concussion in Cricket. Clin J Sport Med 2022;32:e300–7. doi:10.1097/JSM.0000000000000933
Gamble ASD, Bigg JL, Sick S, et al. Helmet Fit Assessment and Concussion Risk in Youth Ice Hockey Players: A Nested Case-Control Study. J Athl Train 2021;56:845–50.
Herman DC, Caswell SV, Kelshaw PM, et al. Association of headgear mandate and concussion injury rates in girls’ high school lacrosse. Br J Sports Med 2022;56:970–4. doi:10.1136/bjsports-2021-105031
Hurst HT, Rylands L, Atkins S, et al. Profiling of translational and rotational head accelerations in youth BMX with and without neck brace. J Sci Med Sport 2018;21:263–7. doi:10.1016/j.jsams.2017.05.018
Kolstad AT, Eliason PH, Galarneau J-M, et al. Protective equipment in youth ice hockey: are mouthguards and helmet age relevant to concussion risk? Br J Sports Med 2023;57:571–7. doi:10.1136/bjsports-2022-105585
Kriz PK, Comstock RD, Zurakowski D, et al. Effectiveness of protective eyewear in reducing eye injuries among high school field hockey players. Pediatrics 2012;130:1069–75. doi:10.1542/peds.2012-1492
Kriz PK, Zurakowski D, Almquist JL, et al. Eye Protection and Risk of Eye Injuries in High School Field Hockey. Pediatrics 2015;136:521–7. doi:10.1542/peds.2015-0216
Lincoln AE, Caswell SV, Almquist JL, et al. Effectiveness of the Women’s Lacrosse Protective Eyewear Mandate in the Reduction of Eye Injuries. Am J Sports Med 2012;40:611–4. doi:10.1177/0363546511428873
Lopez Jr V, Ma R, Weinstein MG, et al. Concussive Injuries in Rugby 7s: An American Experience and Current Review. Medicine & Science in Sports & Exercise 2016;48:1320–30.
Makovec Knight J, Mitra B, McIntosh A, et al. The association of padded headgear with concussion and injury risk in junior Australian football: A prospective cohort study. J Sci Med Sport 2022;25:312–20. doi:10.1016/j.jsams.2021.11.043
Marshall SW, Loomis DP, Waller AE, et al. Evaluation of protective equipment for prevention of injuries in rugby union. Int J Epidemiol 2005;34:113–8.
McGuine T, Post E, Pfaller AY, et al. Does soccer headgear reduce the incidence of sport-related concussion? A cluster, randomised controlled trial of adolescent athletes. Br J Sports Med 2020;54:408–13. doi:10.1136/bjsports-2018-100238
Mihalik JP, McCaffrey MA, Rivera EM, et al. Effectiveness of mouthguards in reducing neurocognitive deficits following sports-related cerebral concussion. Dent Traumatol 2007;23:14–20. doi:10.1111/j.1600-9657.2006.00488.x
Ono Y, Tanaka Y, Sako K, et al. Association between Sports-Related Concussion and Mouthguard Use among College Sports Players: A Case-Control Study Based on Propensity Score Matching. IJERPH 2020;17:4493. doi:10.3390/ijerph17124493
Raaii F, Vaidya N, Vaidya K, et al. Patterns of Mouthguard Utilization Among Atom and Pee Wee Minor Ice Hockey Players: A Pilot Study. Clin J Sport Med 2011;21:320–4. doi:10.1097/JSM.0b013e31821f5cd7
Tierney RT, Higgins M, Caswell SV, et al. Sex differences in head acceleration during heading while wearing soccer headgear. J Athl Train 2008;43:578–84. doi:10.4085/1062-6050-43.6.578
van Ierssel J, Ledoux A-A, Tang K, et al. Sex-Based Differences in Symptoms With Mouthguard Use After Pediatric Sport-Related Concussion. J Athl Train 2021;56:1188–96. doi:10.4085/1062-6050-0393.20
Van Pelt KL, Caccese JB, Eckner JT, et al. Detailed description of Division I ice hockey concussions: Findings from the NCAA and Department of Defense CARE Consortium. J Sport Health Sci 2021;10:162–71. doi:10.1016/j.jshs.2021.01.004
Willmott C, Reyes J, K Nguyen JV, et al. A pilot case crossover study of the use of padded headgear in junior Australian football. Concussion 2022;7:CNC99. doi:10.2217/cnc-2022-0005
Arakkal AT, Barón AE, Lamb MM, et al. Evaluating the effectiveness of traumatic brain injury state laws among high school athletes. Inj Epidemiol 2020;7:12. doi:10.1186/s40621-020-00241-6
Asken BM, Bauer RM, Guskiewicz KM, et al. Immediate Removal From Activity After Sport-Related Concussion Is Associated With Shorter Clinical Recovery and Less Severe Symptoms in Collegiate Student-Athletes. Am J Sports Med 2018;46:1465–74. doi:10.1177/0363546518757984
Asken BM, McCrea MA, Clugston JR, et al. “Playing Through It”: Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. J Athl Train 2016;51:329–35. doi:10.4085/1062-6050-51.5.02
Baugh CM, Meehan WP, McGuire TG, et al. Staffing, Financial, and Administrative Oversight Models and Rates of Injury in Collegiate Athletes. J Athl Train 2020;55:580–6. doi:10.4085/1062-6050-0517.19
Charek DB, Elbin RJ, Sufrinko A, et al. Preliminary Evidence of a Dose-Response for Continuing to Play on Recovery Time After Concussion. J Head Trauma Rehabil 2020;35:85–91. doi:10.1097/HTR.0000000000000476
Emery CA, Warriyar Kv V, Black AM, et al. Factors Associated With Clinical Recovery After Concussion in Youth Ice Hockey Players. Orthop J Sports Med 2021;9:23259671211013370. doi:10.1177/23259671211013370
Miller GF, Sarmiento K, Haarbauer-Krupa J, et al. The Association Between School District-Based Policies Related to Concussions and Concussions Among High School Students. J Sch Health 2022;92:140–7. doi:10.1111/josh.13113
Pierpoint LA, LaBella CR, Collins CL, et al. Injuries in girls’ soccer and basketball: a comparison of high schools with and without athletic trainers. Inj Epidemiol 2018;5:29. doi:10.1186/s40621-018-0159-6
Yang J, Comstock RD, Yi H, et al. New and Recurrent Concussions in High-School Athletes Before and After Traumatic Brain Injury Laws, 2005-2016. Am J Public Health 2017;107:1916–22. doi:10.2105/AJPH.2017.304056
Yang J, Harvey HH, Sullivan L, et al. Association Between Design Elements of Concussion Laws and Reporting of Sports-Related Concussions Among US High School Athletes, 2009-2017. Public Health Rep 2021;136:745–53. doi:10.1177/0033354920988611
Zynda AJ, Worrall HM, Sabatino MJ, et al. Continued play following adolescent sport-related concussion: Prospective data from the North Texas Concussion Registry (ConTex). Appl Neuropsychol Child 2022;11:740–51. doi:10.1080/21622965.2021.1957677
Ali M, Dreher N, Hannah T, et al. Concussion Incidence and Recovery Among Youth Athletes With ADHD Taking Stimulant-Based Therapy. Orthop J Sports Med 2021;9:23259671211032564. doi:10.1177/23259671211032564
Arriaza R, Cierna D, Regueiro P, et al. Low risk of concussions in top-level karate competition. Br J Sports Med 2017;51:226–30. doi:10.1136/bjsports-2016-096574
Augustovičová D, Lystad RP, Arriaza R. Time-Loss Injuries in Karate: A Prospective Cohort Study of 4 Consecutive World Karate Championships. Orthop J Sports Med 2019;7:2325967119865866. doi:10.1177/2325967119865866
Baker M, Quesnele J, Baldisera T, et al. Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion. Musculoskeletal Science and Practice 2019;42:193–7. doi:10.1016/j.msksp.2019.04.002
Biese KM, Winans M, Fenton AN, et al. High School Sport Specialization and Injury in Collegiate Club-Sport Athletes. J Athl Train 2021;56:1271–7. doi:10.4085/1062-6050-0021.21
Caccese JB, Buckley TA, Tierney RT, et al. Head and neck size and neck strength predict linear and rotational acceleration during purposeful soccer heading. Sports Biomech 2018;17:462–76. doi:10.1080/14763141.2017.1360385
Collins CL, Fletcher EN, Fields SK, et al. Neck strength: a protective factor reducing risk for concussion in high school sports. J Prim Prev 2014;35:309–19. doi:10.1007/s10935-014-0355-2
Curran-Sills G, Abedin T. Risk factors associated with injury and concussion in sanctioned amateur and professional mixed martial arts bouts in Calgary, Alberta. BMJ Open Sport Exerc Med 2018;4:e000348. doi:10.1136/bmjsem-2018-000348
Denham BE. Associations Between Sports and Exercise Participation, Use of Narcotic Pain Relievers, and Concussions in High-School Seniors. J Sport Behav 2022;45:17–30.
DePadilla L, Miller GF, Jones SE, et al. Substance Use and Sports- or Physical Activity-Related Concussions Among High School Students. J Sch Nurs 2022;38:511–8. doi:10.1177/1059840520977319
Dezman ZDW, Ledet EH, Kerr HA. Neck strength imbalance correlates with increased head acceleration in soccer heading. Sports Health 2013;5:320–6. doi:10.1177/1941738113480935
Eagle SR, Asken B, Trbovich A, et al. Estimated Duration of Continued Sport Participation Following Concussions and Its Association with Recovery Outcomes in Collegiate Athletes: Findings from the NCAA/DoD CARE Consortium. Sports Med 2022;52:1991–2001. doi:10.1007/s40279-022-01668-1
Eckner JT, Oh YK, Joshi MS, et al. Effect of neck muscle strength and anticipatory cervical muscle activation on the kinematic response of the head to impulsive loads. Am J Sports Med 2014;42:566–76. doi:10.1177/0363546513517869
Ekstrand J, Hägglund M, Fuller CW. Comparison of injuries sustained on artificial turf and grass by male and female elite football players. Scand J Med Sci Sports 2011;21:824–32. doi:10.1111/j.1600-0838.2010.01118.x
Esopenko C, de Souza N, Conway F, et al. Bigger Necks Are Not Enough: An Examination of Neck Circumference in Incoming College Athletes. J Prim Prev 2020;41:421–9. doi:10.1007/s10935-020-00600-5
Filben TM, Tomblin BT, Pritchard NS, et al. Assessing the association between on-field heading technique and head impact kinematics in a cohort of female youth soccer players. Sci Med Footb 2024;8:341–50. doi:10.1080/24733938.2023.2264272
Fuller CW, Dick RW, Corlette J, et al. Comparison of the incidence, nature and cause of injuries sustained on grass and new generation artificial turf by male and female football players. Part 2: training injuries. Br J Sports Med 2007;41 Suppl 1:i27–32. doi:10.1136/bjsm.2007.037275
Gallagher V, Kramer N, Abbott K, et al. The Effects of Sex Differences and Hormonal Contraception on Outcomes after Collegiate Sports-Related Concussion. J Neurotrauma 2018;35:1242–7. doi:10.1089/neu.2017.5453
Gutierrez GM, Conte C, Lightbourne K. The relationship between impact force, neck strength, and neurocognitive performance in soccer heading in adolescent females. Pediatr Exerc Sci 2014;26:33–40.
Harriss A, Johnson AM, Walton DM, et al. Head impact magnitudes that occur from purposeful soccer heading depend on the game scenario and head impact location. Musculoskelet Sci Pract 2019;40:53–7.
Koh JO, Cassidy JD. Incidence Study of Head Blows and Concussions in Competition Taekwondo. Clin J Sport Med 2004;14:72–9.
Kriz PK, Stein C, Kent J, et al. Physical Maturity and Concussion Symptom Duration among Adolescent Ice Hockey Players. J Pediatr 2016;171:234–9.
Li AY, Durbin JR, Hannah TC, et al. High altitude modulates concussion incidence, severity, and recovery in young athletes. Brain Inj 2022;36:733–9. doi:10.1080/02699052.2022.2035435
Meyers MC. Incidence, mechanisms, and severity of match-related collegiate women’s soccer injuries on FieldTurf and natural grass surfaces: a 5-year prospective study. Am J Sports Med 2013;41:2409–20. doi:10.1177/0363546513498994
Okoruwa ET, Abbott A, Stamm M, et al. Sport Specialization Classification and Injury Risk in Female Athletes. Sports Health 2022;14:797–804. doi:10.1177/19417381221123532
Peek K, McKay M, Fu A, et al. The effect of ball characteristics on head acceleration during purposeful heading in male and female youth football players. Sci Med Footb 2021;5:195–203. doi:10.1080/24733938.2021.1897657
Raikes AC, Athey A, Alfonso-Miller P, et al. Insomnia and daytime sleepiness: risk factors for sports-related concussion. Sleep Med 2019;58:66–74. doi:10.1016/j.sleep.2019.03.008
Reed N, Taha T, Monette G, et al. A Preliminary Exploration of Concussion and Strength Performance in Youth Ice Hockey Players. Int J Sports Med 2016;37:708–13. doi:10.1055/s-0042-104199
Reha T, McNabb C, Netto K, et al. Head Accelerations during a 1-on-1 Rugby Tackling Drill Performed by Experienced Rugby Union Players. Brain Sci 2021;11:1497. doi:10.3390/brainsci11111497
Riegler KE, Guty ET, Thomas GA, et al. Prospective Implications of Insufficient Sleep for Athletes. J Athl Train 2023;58:414–22. doi:10.4085/1062-6050-0078.22
Rogerson CE, Jackson BC, Breedlove KM, et al. The Effects of Preparedness and Activity on Head Impacts in Lacrosse Athletes. International Journal of Athletic Therapy and Training 2023;28:239–43. doi:10.1123/ijatt.2022-0014
Sarmiento K, Miller GF, Jones SE. Sports-Related Concussions and Adverse Health Behaviors Among Middle and High School Students. Am J Sports Med 2023;51:503–10. doi:10.1177/03635465221141440
Schulz MR, Marshall SW, Mueller FO, et al. Incidence and risk factors for concussion in high school athletes, North Carolina, 1996-1999. Am J Epidemiol 2004;160:937–44. doi:10.1093/aje/kwh304
Sherman K, Tyree P, Ford AI, et al. Association between steroid use and concussions among high school athletes: a cross-sectional analysis of the Youth Risk Behavior Surveillance System. J Osteopath Med 2024;124:27–34. doi:10.1515/jom-2023-0133
Smith DW, Myer GD, Currie DW, et al. Altitude Modulates Concussion Incidence: Implications for Optimizing Brain Compliance to Prevent Brain Injury in Athletes. Orthop J Sports Med 2013;1:2325967113511588. doi:10.1177/2325967113511588
Spiera Z, Hannah T, Li A, et al. Nonsteroidal anti-inflammatory drug use and concussions in adolescent athletes: incidence, severity, and recovery. J Neurosurg Pediatr 2021;28:476–82. doi:10.3171/2021.2.PEDS2115
Stockbridge MD, Keser Z, Newman RS. Concussion in Women’s Flat-Track Roller Derby. Front Neurol 2022;13:809939. doi:10.3389/fneur.2022.809939
Whatman C, van den Berg C, Black AM, et al. High Sport Specialization Is Associated With More Musculoskeletal Injuries in Canadian High School Students. Clin J Sport Med 2023;33:233–8. doi:10.1097/JSM.0000000000001100
National Institute of Health. NIH study qualtiy assessment tools. 2021. Available: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools
Fownes-Walpole M, Heyward O, Till K, et al. Combining evidence and practice to optimise neck training aimed at reducing head acceleration events in sport: a systematic review and Delphi-consensus study. Br J Sports Med 2025;59:1027–42. doi:10.1136/bjsports-2024-108847
Hislop MD, Stokes KA, Williams S, et al. Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial. Br J Sports Med 2017;51:1140–6. doi:10.1136/bjsports-2016-097434
Attwood MJ, Roberts SP, Trewartha G, et al. Efficacy of a movement control injury prevention programme in adult men’s community rugby union: a cluster randomised controlled trial. Br J Sports Med 2018;52:368–74. doi:10.1136/bjsports-2017-098005
Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: Cluster randomised controlled trial. BMJ 2009;338:95–9.
Patterson BE, Donaldson A, Cowan SM, et al. Evaluation of an injury prevention programme (Prep-to-Play) in women and girls playing Australian Football: design of a pragmatic, type III, hybrid implementation-effectiveness, stepped-wedge, cluster randomised controlled trial. BMJ Open 2022;12:e062483. doi:10.1136/bmjopen-2022-062483
Stokes KA, Locke D, Roberts S, et al. Does reducing the height of the tackle through law change in elite men’s rugby union (The Championship, England) reduce the incidence of concussion? A controlled study in 126 games. Br J Sports Med 2021;55:220–5. doi:10.1136/bjsports-2019-101557
van Tonder R, Starling L, Surmon S, et al. Tackling sport-related concussion: effectiveness of lowering the maximum legal height of the tackle in amateur male rugby - a cross-sectional analytical study. Inj Prev 2023;29:56–61. doi:10.1136/ip-2022-044714
Heming EE, Sobry AJ, Cairo AL, et al. Higher Rates of Head Contacts, Body Checking, and Suspected Injuries in Ringette Than Female Ice Hockey: Time to Ring in Opportunities for Prevention. Clin J Sport Med 2023;33:151–6. doi:10.1097/JSM.0000000000001089
Krolikowski MP, Black AM, Palacios-Derflingher L, et al. The Effect of the “Zero Tolerance for Head Contact” Rule Change on the Risk of Concussions in Youth Ice Hockey Players. Am J Sports Med 2017;45:468–73. doi:10.1177/0363546516669701
Cross MJ, Tucker R, Raftery M, et al. Tackling concussion in professional rugby union: a case–control study of tackle-based risk factors and recommendations for primary prevention. Br J Sports Med 2019;53:1021–5. doi:10.1136/bjsports-2017-097912
Tucker R, Raftery M, Fuller GW, et al. A video analysis of head injuries satisfying the criteria for a head injury assessment in professional Rugby Union: a prospective cohort study. Br J Sports Med 2017;51:1147–51. doi:10.1136/bjsports-2017-097883
Tucker R, Raftery M, Kemp S, et al. Risk factors for head injury events in professional rugby union: a video analysis of 464 head injury events to inform proposed injury prevention strategies. Br J Sports Med 2017;51:1152–7. doi:10.1136/bjsports-2017-097895
Rugby Football Union. Rationale and evidence for proposal to reduce the tackle height in england’s community game. London, UK, 2023.
Shill IJ, Galarneau J-M, Hendricks S, et al. Tackle characteristics associated with suspected concussion in female varsity rugby union: a case-control video analysis study. Int J Perform Anal Sport 2025;25:386–404. doi:10.1080/24748668.2024.2413802
Dane K, West SW, Hendricks S, et al. Are we tackle ready? Cross‐sectional video analysis of match tackle characteristics in elite women’s Rugby Union. Eur J Sport Sci 2024;24:999–1009. doi:10.1002/ejsc.12120
Broglio SP, Martini D, Kasper L, et al. Estimation of head impact exposure in high school football: implications for regulating contact practices. Am J Sports Med 2013;41:2877–84. doi:10.1177/0363546513502458
Broglio SP, Williams RM, O’Connor KL, et al. Football Players’ Head-Impact Exposure After Limiting of Full-Contact Practices. J Athl Train 2016;51:511–8. doi:10.4085/1062-6050-51.7.04
Pfaller AY, Brooks MA, Hetzel S, et al. Effect of a New Rule Limiting Full Contact Practice on the Incidence of Sport-Related Concussion in High School Football Players. Am J Sports Med 2019;47:2294–9. doi:10.1177/0363546519860120
Bretzin AC, Tomczyk CP, Wiebe DJ, et al. Avenues for Sport-Related Concussion Prevention in High School Football: Effect of Limiting Collision Practices. J Athl Train 2022;57:733–40. doi:10.4085/1062-6050-0341.21
Dick R, Ferrara MS, Agel J, et al. Descriptive epidemiology of collegiate men’s football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train 2007;42:221–33.
Stemper BD, Shah AS, Harezlak J, et al. Repetitive Head Impact Exposure in College Football Following an NCAA Rule Change to Eliminate Two-A-Day Preseason Practices: A Study from the NCAA-DoD CARE Consortium. Ann Biomed Eng 2019;47:2073–85. doi:10.1007/s10439-019-02335-9
Stemper BD, Shah AS, Mihalik JP, et al. Head Impact Exposure in College Football after a Reduction in Preseason Practices. Med Sci Sports Exerc 2020;52:1629–38. doi:10.1249/MSS.0000000000002283
Recker R, Myers A, Desai N, et al. Headgear use in girls’ lacrosse-stakeholders not ready for change. Front Sports Act Living 2024;6:1363007. doi:10.3389/fspor.2024.1363007
Makovec Knight J, Nguyen JVK, Mitra B, et al. Soft-shell headgear, concussion and injury prevention in youth team collision sports: a systematic review. BMJ Open 2021;11:e044320. doi:10.1136/bmjopen-2020-044320
McIntosh AS, McCrory P, Finch CF, et al. Does padded headgear prevent head injury in rugby union football? Med Sci Sports Exerc 2009;41:306–13. doi:10.1249/MSS.0b013e3181864bee
Stokes KA, Cross M, Williams S, et al. Padded Headgear does not Reduce the Incidence of Match Concussions in Professional Men’s Rugby Union: A Case-control Study of 417 Cases. Int J Sports Med 2021;42:930–5. doi:10.1055/a-1345-9163
Knapik JJ, Hoedebecke BL, Rogers GG, et al. Effectiveness of Mouthguards for the Prevention of Orofacial Injuries and Concussions in Sports: Systematic Review and Meta-Analysis. Sports Med 2019;49:1217–32. doi:10.1007/s40279-019-01121-w
Stenger JM, Lawson EA, Wright JM, et al. Mouthguards: protection against shock. The Journal of the American Dental Association 1964;69:273–81.
Tanaka Y, Tsugawa T, Maeda Y. Effect of mouthguards on impact to the craniomandibular complex. Dent Traumatol 2017;33:51–6. doi:10.1111/edt.12283
Benson BW, Hamilton GM, Meeuwisse WH, et al. Is protective equipment useful in preventing concussion? A systematic review of the literature. Br J Sports Med 2009;43 Suppl 1:i56–67. doi:10.1136/bjsm.2009.058271
Schneider KJ, Meeuwisse WH, Palacios-Derflingher L, et al. Changes in Measures of Cervical Spine Function, Vestibulo-ocular Reflex, Dynamic Balance, and Divided Attention Following Sport-Related Concussion in Elite Youth Ice Hockey Players. J Orthop Sports Phys Ther 2018;48:974–81. doi:10.2519/jospt.2018.8258
Collins CL, Fletcher EN, Fields SK, et al. Neck Strength: A Protective Factor Reducing Risk for Concussion in High School Sports. J Primary Prevent 2014;35:309–19. doi:10.1007/s10935-014-0355-2
