 |
| MMWR Weekly Vol. 65, No. 52 January 06, 2017 |
| PDF of this issue |
Kristen L. Kucera, PhD1; Rebecca K. Yau, PhD1,2; Johna Register-Mihalik, PhD3; Stephen W. Marshall, PhD2; Leah C. Thomas, MS1; Susanne Wolf1; Robert C. Cantu, MD4; Frederick O. Mueller, PhD1; Kevin M. Guskiewicz, PhD3 (View author affiliations)
View suggested citationSummary
What is already known about this topic?
Fatalities resulting from catastrophic brain and spinal cord injuries occur infrequently among high school and college football players.
What is added by this report?
During 2005–2014, a total of 28 traumatic brain and spinal cord injury deaths in high school and college football were identified (2.8 deaths per year). The most common playing positions of those fatally injured were running back and linebacker. Approximately 18% of identified high school brain injury deaths were preceded by an earlier concussion, which might have led to second impact syndrome.
What are the implications for public health practice?
Implementing enhanced safety measures to prevent fatalities from catastrophic brain and spinal cord injuries among high school and college football players has the potential to reduce the number of these fatalities. Continued surveillance is important to monitor the circumstances of these deaths and develop risk scenarios to improve prevention measures.
Kristen L. Kucera, PhD1; Rebecca K. Yau, PhD1,2; Johna Register-Mihalik, PhD3; Stephen W. Marshall, PhD2; Leah C. Thomas, MS1; Susanne Wolf1; Robert C. Cantu, MD4; Frederick O. Mueller, PhD1; Kevin M. Guskiewicz, PhD3 (View author affiliations)
View suggested citation
An estimated 1.1 million high school and 75,000 college athletes participate in tackle football annually in the United States. Football is a collision sport; traumatic injuries are frequent (1,2), and can be fatal (3). This report updates the incidence and characteristics of deaths caused by traumatic brain injury and spinal cord injury (4) in high school and college football and presents illustrative case descriptions. Information was analyzed from the National Center for Catastrophic Sport Injury Research (NCCSIR). During 2005–2014, a total of 28 deaths (2.8 deaths per year) from traumatic brain and spinal cord injuries occurred among high school (24 deaths) and college football players (four deaths) combined. Most deaths occurred during competitions and resulted from tackling or being tackled. All four of the college deaths and 14 (58%) of the 24 high school deaths occurred during the last 5 years (2010–2014) of the 10-year study period. These findings support the need for continued surveillance and safety efforts (particularly during competition) to ensure proper tackling techniques, emergency planning for severe injuries, availability of medical care onsite during competitions, and assessment that it is safe to return to play following a concussion.
NCCSIR has been conducting catastrophic injury surveillance at the national level for high school and collegiate football since 1965 (5) and for all sports since 1982 (6). Deaths were identified through ongoing and systematic monitoring of public media sources (e.g., online search engines and news search engines) and individual reports from national and state-level organizations, clinicians, school authorities, and researchers. Once a death was identified, NCCSIR researchers contacted family members or school staff members to gather additional details. When possible, NCCSIR obtained medical examiner reports. Information was collected about the athlete’s age and level of play; player position and activity; and injury type, medical care, and cause of death.
The events included in this study were defined as fatal traumatic brain and spinal cord injuries that occurred during a scheduled team activity (game, practice, or conditioning session) and were directly related to football-specific activities (e.g., tackling or being tackled). Each fatality report was manually reviewed for inclusion and classification. Fatality rates per 1 million players were calculated using National Federation of State High School Associations and National Collegiate Athletic Association participation statistics as the denominators. The causes and potential strategies to prevent these injuries were described in association with the 10 Haddon energy damage countermeasures (7). All procedures were reviewed and approved by the Institutional Review Board of the University of North Carolina at Chapel Hill.
During 2005–2014, a total of 24 high school and four college football–related traumatic brain and spinal cord injury fatalities were identified, for a combined average of 2.8 fatalities per year. Among the 24 high school fatalities (Table 1), 22 (92%) involved head/brain injuries. All four college fatalities involved a brain injury. Subdural hematoma was the most common diagnosis for both high school and college fatalities (46% overall). Four (18%) of the 22 high school players who died from brain injuries had sustained a concussion within 4 weeks of the event, and second impact syndrome (in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling) was implicated in three of these four events.
Among the 24 high school fatalities (Table 1), 20 (83%) occurred during a game and during the regular season; 17 (71%) involved tackling or being tackled. Among the four college fatalities, two occurred during a regular season game, and two occurred during spring football. The most common player positions among those fatally injured were running back (32% of players overall) and linebacker (21%). Of the 28 deaths, head first/head down contact was identified in eight deaths. Six illustrative cases provide associations with the Haddon energy damage countermeasures and extensions to football recommendations for preventing traumatic brain and spinal cord fatalities (Table 2).
The average number of high school deaths per year was 2.4 (standard deviation [SD] = 2.2) and ranged from zero to seven deaths annually. The average number of deaths among college players per year was 0.4 (SD = 0.7) and ranged from zero to two deaths annually. For 2 years (2007 and 2012) of the 10-year study period, no traumatic brain or spinal cord injury deaths were reported among either high school or college football players. Fatality rates over the study period were 5.96 fatalities per 1 million college football players (95% confidence interval [CI] = 0.12–11.81) and 2.18 fatalities per 1 million high school football players (CI = 1.31–3.06) (Figure). All four of the college deaths and 14 (58%) of the 24 high school deaths occurred during the last 5 years (2010–2014) of the 10-year study period.
Discussion
The finding of an annual average of 2.8 brain and spinal cord injury deaths for high school and college football combined is consistent with a previous report of 3.1 brain injury fatalities annually during 1990–2010 (4). Also consistent with previous studies (3,4), most brain and spinal cord injury deaths occurred during competition, among players at running back and linebacker positions, and as a result of tackling or being tackled.
Head first/head down contact was identified as contributing to eight of the 28 deaths. This emphasizes the importance of instruction in proper tackling techniques (both delivery and receipt of tackles) for all players, but particularly for running backs, linebackers, and defensive backs. A previous evaluation of football tackling programs among youth league football players indicated a reduction in concussions in practice and games when education of coaches was combined with practice contact restrictions (8), providing evidence that these programs might have a positive impact on reducing nonfatal head injuries among youth league players. However, it is unclear whether older players who learned high risk methods can be retrained in new techniques. Football is a collision sport played at high velocity, and players must act and react quickly. In such situations, new techniques might be difficult to deploy, resulting in players possibly reverting to past behaviors and reactions unless coaches routinely intervene to correct their technique.
The finding that 18% of high school players with fatal traumatic brain injuries had a concussion <4 16="" 20-year="" 30="" a="" brain="" concussion="" consistent="" days="" death="" died="" earlier="" football="" found="" from="" had="" i="" injuries="" is="" of="" over="" period="" players="" previous="" study="" that="" traumatic="" weeks="" who="" with="" within="">4
The cases described in this report illustrate the importance of emergency preparedness, recognition, and access to medical services. All schools should have written emergency action plans specific to their school and venue that are rehearsed annually by coaches and staff (9). The availability of medical professionals onsite who are trained to recognize and act in emergency situations is critical in catastrophic football injury events. Many schools employ certified athletic trainers, and for competitions, have emergency medical services onsite. However, nationally, 30% of public high schools do not have access to an athletic trainer, and 50% do not have athletic trainers present at practices (10). One of the deaths in this report occurred during a junior varsity football scrimmage when emergency medical services were not onsite and arrival of emergency medical services took 15 minutes because of traffic. Current best practices include access to athletic trainers for practices and competition and maintaining emergency medical services onsite during competitions (9).
The findings in this report are subject to at least four limitations. First, most events were captured through publicly available media sources, and it is possible that some football deaths were missed. Second, football participation numbers are representative of National Federation of State High School Associations and National Collegiate Athletic Association-affiliated schools and likely underestimate the actual number of football participants. Third, whenever possible, medical diagnoses and medical examiner report causes of death were used, however, the exact diagnosis was unknown for seven of the traumatic brain injury deaths. Information availability might be hampered by the sensitivity surrounding a fatal event, potential litigation, and inability to talk with persons involved. Finally, public interest and media attention about sport-related deaths and traumatic brain injuries increased during the study period, and it is unknown how this might have affected the identification of fatal injuries over time.
These findings support continued surveillance and safety efforts to ensure proper tackling techniques, emergency planning, and medical care, particularly during competition, and adherence to protocols for safe return-to-play after a concussion. These measures will also reduce the risk for concussion and improve treatment and management after a concussion is sustained. CDC provides emergency action plan templates and guidance (https://www.cdc.gov/niosh/docs/2004-101/emrgact/emrgact1.html) and information about concussions through the CDC HEADS UP program (https://www.cdc.gov/headsup/). Information on state laws related to concussions is available at https://www.ncsl.org/research/health/traumatic-brain-injury-legislation.aspx. Catastrophic sport injuries can be reported to the National Center for Catastrophic Sport Injury Research at http://nccsir.unc.edu/.
Acknowledgments
Julie Gilchrist, MD, National Center for Injury Prevention and Control, CDC; R. Dawn Comstock, PhD, Douglas J. Casa, PhD, Tom P. Dompier, PhD, Jonathan A. Drezner, MD, Zackary Y. Kerr, PhD, David Klossner, PhD, Rebecca L. Stearns, PhD, Consortium for Catastrophic Injury Monitoring in Sport. The National Center for Catastrophic Sport Injury Research is funded by the following organizations: the American Football Coaches Association, the National Athletic Trainers’ Association, the National Collegiate Athletic Association, the National Federation of State High School Associations, the National Operating Committee on Standards for Athletic Equipment, and the American Medical Society for Sports Medicine.
Corresponding author: Kristen Kucera, kkucera@email.unc.edu, 919-962-6228.
1National Center for Catastrophic Sport Injury Research, Department of Exercise & Sport Science, University of North Carolina at Chapel Hill; 2Injury Prevention Research Center, University of North Carolina at Chapel Hill; 3Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise & Sport Science, University of North Carolina at Chapel Hill; 4Emerson Hospital and Boston University, Massachusetts.
References
- Dompier TP, Kerr ZY, Marshall SW, et al. Incidence of concussion during practice and games in youth, high school, and collegiate American football players. JAMA Pediatr 2015;169:659–65.CrossRef PubMed
- Kerr ZY, Collins CL, Fields SK, Comstock RD. Epidemiology of player—player contact injuries among US high school athletes, 2005–2009. Clin Pediatr (Phila) 2011;50:594–603. CrossRefPubMed
- Cantu RC, Mueller FO. Brain injury-related fatalities in American football, 1945–1999. Neurosurgery 2003;52:846–53. CrossRef PubMed
- Boden BP, Breit I, Beachler JA, Williams A, Mueller FO. Fatalities in high school and college football players. Am J Sports Med 2013;41:1108–16. CrossRef PubMed
- Mueller FO, Blyth CS. Fatalities from head and cervical spine injuries occurring in tackle football: 40 years’ experience. Clin Sports Med 1987;6:185–96. PubMed
- Cantu RC, Mueller FO. The prevention of catastrophic head and spine injuries in high school and college sports. Br J Sports Med 2009;43:981–6. CrossRef PubMed
- Haddon W . Energy damage and the ten countermeasure strategies. J Trauma 1973;13:321–31. CrossRef PubMed
- 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;3:2325967115594578. CrossRef PubMed
- Casa DJ, Guskiewicz KM, Anderson SA, et al. National athletic trainers’ association position statement: preventing sudden death in sports. J Athl Train 2012;47:96–118. PubMed
- Pryor RR, Casa DJ, Vandermark LW, et al. Athletic training services in public secondary schools: a benchmark study. J Athl Train 2015;50:156–62. CrossRef PubMed
.png)
No hay comentarios:
Publicar un comentario