Female soccer players playing elite or select soccer before high school sustained concussions at a rate higher than their high school and college counterparts, most continued to play despite experiencing symptoms, and less than half sought medical attention, a first-of-its-kind study finds.
Analyzing data collected over a four-year period from 351 players between the ages of 11 and 14 on elite and travel soccer teams, researchers at the University of Washington reported:
The study's authors offered several possible explanations for the concussion rate in female middle school soccer players four times higher than in the most recent study of female high school soccer players. They could be explained, said lead author, John O'Kane, MD, of the University of Washington Sports Medicine Clinic, by differences in methodology (prospective data collection with weekly interviews in the current study versus data reported by athletic trainers in the other studies), and under-reporting in previous studies that captured concussions only in athletes seeking medical attention.
Noting other studies finding that between one-third and one-half of players report concussion symptoms for which they did not seek medical attention, and the fact that, in the current study, only 44.1% of athletes identified through the weekly interviews sought medical evaluation by a QHP, and that the concussion rate considering only those diagnosed by a QHP was far lower than the overall rate reported (.4 per 1,000 AEs versus 1.3 per 1,000 AEs). "We suspect that underreporting in previous studies explains the lower rates observed," said Dr. O'Kane.
The high percentage of athletes reporting that they continued to play despite experiencing concussion symptoms, while similar to the rates reported in other studies, is concerning, as the failure to diagnose concussions in athletes can lead to further damage to the brain before full recovery, expose them to the cumulative effects of injuries and increased risk of second impact syndrome. [5-7]
"The fact that 58% of athletes continued to play with their concussion symptoms is troubling," said Tracey Covassin PhD, ATC, and Associate Professor and Undergraduate Athletic Training Program Director at Michigan State University, and an expert in sport-related concussions; "not from a research perspective but from an educational perspective and safety concern for the athletes. I feel like we are trying to educate athletes on the signs and symptoms of concussion and dangers of playing with a concussion, but either we are not reaching everyone (which is true) or athletes are continuing to hide their symptoms so they can continue to play."
While O'Kane said there was some evidence that concussion education could improve the percentage of athletes reporting concussions, pointing to a 2012 study finding that high school athletes receiving concussion education were twice as likely to report symptoms to coaches compared with those with no education (72% vs. 36%), he acknowledged that a 2013 study  (also by researchers at the University of Washington) found that many high school soccer players, despite understanding the symptoms of concussion and the potentially severe complications from playing with concussion, would continue to play despite symptoms.
Besides the 2013 University of Washington study, a number of other recent studies have found education ineffective in improving self-reporting by athletes, adding to a growing body of evidence challenging the conventional wisdom that inadequate athlete concussion knowledge is the principal barrier to increased reporting, and suggesting that one of the best ways to combat underreporting by athletes of concussion symptoms may be to shift the focus of educational efforts towards helping coaches facilitate concussion reporting , the theory being that athletes will be more likely to report concussion symptoms if they no longer think that they will be punished by the coach for reporting, such as by losing playing time or their starting position, perceived by their teammates as letting them down, or viewed by their coach as "weak," all of which have been documented in numerous studies over the past decade as reasons athletes are reluctant to report concussion symptoms.[8-17]
Dr. O'Kane and his colleagues recognized that the study had several limitations;
"I think the biggest limitation with the study was that parents reported their child's concussion," said Dr. Covassin. "However, due to the parent not being qualified to diagnose a concussion, I think the prevalence and injury rate would have been higher if they had a certified athletic trainer present for practices and games."
"I have great respect for the researchers at Harborview and think this was a good study, and was great to see somebody providing data on youth younger than high school age," said Dawn Comstock, an epidemiologist at the Colorado School of Public Health who has studied extensively sports injuries at the high school level.
"That said, Comstock said that, as with all studies, there were a few methodological issues. "First, this is relatively small regional sample from a population with which this group has done quite a bit of work, so these parents may be more knowledgeable about concussions than other parents across the country." Second, like Dr. Covassin, she noted that it was based on a parent report of concussion symptoms, with about half of the reported cases never diagnosed by a medical professional. As a result, Comstock said, while the authors discuss the possibility of under-reporting in other studies, she was "more concerned with over-reporting in this study."
Finally, she noted that "the researchers never tell us how many of the heading-related concussions were from athlete-athlete contact versus contact with the ball versus contact with the ground. "This is disappointing, Comstock said, "since they had the data and just didn't present it," an omission that she felt was was "really important from a prevention standpoint: if we want to significantly reduce concussions in youth soccer, [we need to know] do we need to ban heading altogether, or would we be successful if rules prohibiting athlete-athlete contact during heading were enacted and strictly enforced?"
In the final analysis, says Dr. Covassin, the current study "demonstrates three things: First, we need to conduct better education for the younger population on the signs and symptoms of concussion. Second, we need to do a better job on educating players on the dangers of playing with a concussion, especially in this younger population. And, third, we need to conduct more research on youth athletes (5-13 years old) and female athletes."
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