Presentation delivered at University of Michigan Injury Center Sport Concussion Summit, Ann Arbor, September 24, 2015

1. Traumatic Brain Injury In Sport:
Incidence of Injury
Kevin Guskiewicz, PhD, ATC
Kenan Distinguished Professor
Department of Exercise and Sport Science
UNIVERSITY of NORTH CAROLINA at CHAPEL HILL
University of Michigan Injury Center
Concussion Summit Sept. 24, 2015

3. Are football programs’ millions in profits exploitation? Or are
they still a celebration of amateur sport?
Does football’s inherent danger and violence have any place in
institutions of higher learning? Or does it provide young men
with educational opportunities they would not otherwise
have?
Arguing for the motion will be Malcolm Gladwell and Buzz Bissinger, arguing against will be Jason
Whitlock and Tim Green.
May 8, 2012 – On-line debate FOR A.tv

4. 10 Ideas That Changed the World
in 2012

5. Cumulative risks for youth athletes
Should kids be playing contact or collision sports?

6. National Center for Catastrophic Sport Injury Research: Direct (traumatic)
Head and Neck Catastrophic Injuries – All sports all levels
0
50
100
150
200
250
300
Numberofevents
Total Fatal Non-fatal neck Non-fatal Head

7. Catastrophic Head & Neck Injuries
Academic Year 2014-15
Sport n %
Football 22 84.6
Lacrosse 1 3.9
Soccer 3 11.5
Level
Professional 3 11.5
Collegiate 4 15.4
High school 18 69.2
Youth league 1 3.9
Part
Head 13 50.0
Neck 12 46.2
Spine 1 3.9
Disability n %
Fatal 6 23.1
Paralysis 1 3.9
Severe no paralysis 9 34.6
Temporary Paralysis 6 23.1
Unknown 4 15.4
Activity
Game 24 92.3
Practice 1 3.9
Unknown 1 3.9
TOTAL head & spine 26 100
TOTAL events 81 32.1
*AY 2013/14 there were 31 catastrophic head & spine injuries captured
Courtesy of National Center for Catastrophic Sport Injury Research

8. Courtesy of National Center for Catastrophic Sport Injury Research
Football
Indirect Fatalities (Heat Stroke, Cardiac, etc.) vs.
Direct (Head & Neck) Fatalities

9. Characteristics of 2014 Football-Related Direct Fatalities
Courtesy of National Center for Catastrophic Sport Injury Research

10. Concussion Rates per 10,000 AEs
Sport Overall Rank Practice Rank
Football 7.44 1 3.54 1
Boys’ Ice Hockey 6.57 2 1.48 5
Boys’ Lacrosse 4.97 3 1.64 4
Girls’ Soccer 4.63 4 0.96 10
Girls’ Lacrosse 3.82 5 1.41 6
Girls’ Basketball 3.12 6 1.08 9
Boys’ Wrestling 3.08 7 2.08 3
Boys’ Soccer 2.68 8 0.65 13
Girls’ Field Hockey 2.63 9 1.19 7
Cheerleading 2.02 10 2.16 2
Boys’ Basketball 1.68 11 0.82 11
Girls’ Softball 1.66 12 1.11 8
Cheerleaders don’t always have a safe practice space.
Cheerleading practice concussions occur on tile, asphalt, and concrete.
Courtesy of R. Dawn Comstock, PhD;
National High School Sports-Related Injury Surveillance System (High School RIO)

11. Concussion Burden High School RIOTM Data
Courtesy of R. Dawn Comstock, PhD;
National High School Sports-Related Injury Surveillance System (High School RIO)

12. State Concussion Laws
Sports Concussion Legislation – All 50 states (2009-2014)
Essential components
1) Education (athletes, parents, coaches).
2) Instituting a concussion policy and emergency action plan.
3) Removal from practice or play at the
time of suspected concussion.
4) Medical evaluation and return to play
clearance by a health care provider with
training in concussion management.

13. State Youth Sport Concussion Laws Enacted by Year
K.M. Lowrey, 2014

14. Concussion Rates per 10,000 AE Over Time:
High School RIO Data
Courtesy of R. Dawn Comstock, PhD;
National High School Sports-Related Injury Surveillance System (High School RIO)
Concussion crisis?
No!

15. Trends Over Time: Compliance with Return to Play Guidelines
Following Concussion (All Sports)
07/08 08/09 09/10 10/11 11/12 12/13
<1 day 7.9 2.6 1.5 0.8 1.8 0.6
1-2 days 6.7 6.4 3.9 2.4 1.9 0.8
3-6 days 21.4 19.5 17.9 12.9 8.9 8.3
Season ended 0.8 0.1 8.7 12.2 14.2 14.5
Athlete decides not to
continue
0.4 1.4 1.2 1.4 1.9 1.9
% of Student Athletes in Each Category of RTP by Year
“Education (coupled with legislation?) has been effective!”
Courtesy of R. Dawn Comstock, PhD;
National High School Sports-Related Injury Surveillance System (High School RIO)

16. Across 25 sports, no significant increase detected over the past 10 years;
Lacrosse and football showed linear trends suggesting an increase in reported concussions.

17. Concussion Incidence
• HS overall rate (2011/12 HS RIO): 0.51 per 1,000 AEs
– 2x greater than rate for 2005/2006 season
Rosenthal, 2014
• NCAA overall rate (2009/2010 to 2013/2014 NCAA
ISS):0. 447 per 1,000 AEs
Zuckerman, 2015

18. Concussion incidence in the NFL
•1996 – 2001:
0.41 concussions per game (Pellman et al, 2004)
•2002 – 2007:
0.38 concussions per game (Casson et al, 2010)
•2010 – 2014:
0.66 concussions per game (Clark et al, Unpublished)

19. Incidence rate by type of play (NFL)
Type of
Play
Injuries
Frequency of
Play Type
Adjusted Frequency
of Play Types
Incidence Rate per 1,000
Plays (95% C.I.)
Rate Ratio (95% C.I.)
Run 123 58,133 28,572 4.31. (3.61 – 5.14) –
Pass 241 73,703 36,183 6.67 (5.87 – 7.56) 1.55 (1.25 – 1.92)
Punt 17 10,256 5,043 3.37 (2.10 – 5.42) 0.78 (0.47 – 1.30)
Field Goal 4 4,140 2,037 1.96 (0.74 – 5.23) 0.46 (0.17 – 1.73)
Kickoff 44 6,362 5,043 14.14 (10.52 – 19.00) 3.28 (2.33 – 4.63)

20. Incidence rate by time of play (NFL)
Half Quarter Number of
Injuries
Adjusted Frequency of
Plays
Incidence Rate per 1000
Plays (95% C.I.)
Rate Ratio (95% C.I.)
First
First 91
38,650 4.68 (4.05 – 5.42) –
Second 90
Second
Third 122
38,619 6.32 (5.57 – 7.16) 1.35 (1.11 – 1.64)
Fourth 122
Overtime 4 N/A N/A

21. Injurious impact type by time of play (NFL)
Half (%)
First Second
helmet-to-ground 78 (33.8) 84 (27.0) 162 (29.9)
helmet-to-helmet 71 (30.7) 104 (33.4) 175 (32.3)
helmet-to-pad 82 (35.5) 123 (39.6) 205 (37.8)
231 311 542
Χ2 = 2.900 , P=0.235

22. Impact location by time of play (NFL)
Half
First Second
Back 6 14 20
7.32 11.38
Crown 14 16 30
17.07 13.01
Facemask 8 18 26
9.76 14.63
Front 10 16 26
12.2 13.01
Left 16 24 40
19.51 19.51
Right 28 35 63
34.15 28.46
82 123 205
Helmet-to-Pad Impacts
Half
First Second
Back 5 7 12
7.14 6.8
Crown 10 21 31
14.29 20.39
Facemask 6 11 17
8.57 10.68
Front 11 15 26
15.71 14.56
Left 24 25 49
34.29 24.27
Right 14 24 38
20 23.3
70 103 173
Helmet-to-Helmet Impacts
Χ2 = 2.781
P=0.734
Χ2 = 2.856
P=0.722

23. Table 2. Regular Season Game Kickoff Statistics in 2011; 3-year Comparison
Result of Kickoff
Year
Total
Returns
Touchbacks
Fair
Catches
Kick Out of
Bounds
Short Free or
Onside Kicks
Opponent
Received
Total
Kickoffs
2008 2114 371 7 36 47 1 2576
2009 2004 401 12 30 36 1 2484
2010 2034 416 7 39 43 0 2539
2011 1375 1120 1 26 50 0 2572
Average 2008-2010 2050.7 396 8.7 35 42 0.7 2533
NFL’s 2011 Kick-off Rule Change
33% reduction in the number of returned kickoffs

24. Table 3. Significant Injuries As a Function of Kickoff Plays 2011 Regular Season; 3-year
Comparison
Regular Season Games
Year Concussions Neck/Spine Fractures ACL Sprain All Injuries
2008
(N=2576)
26
(1.0%)
12
(0.5%)
10
(0.4%)
3
(0.1%)
152
(5.9%)
2009
(N=2484)
25
(1.0%)
7
(0.3%)
6
(0.2%)
2
(0.1%)
147
(5.9%)
2010
(N=2539)
28
(1.1%)
7
(0.3%)
11
(0.4%)
8
(0.3%)
135
(5.3%)
2011
(N=2572)
15
(0.6%)
8
(0.3%)
8
(0.3%)
7
(0.3%)
136
(5.3%)
Average 2008-2010
(N=2533)
26.3
(1.0%)
8.7
(0.3%)
9.0
(0.4%)
4.3
(0.2%)
144.7
(5.7%)
NFL’s 2011 Kick-off Rule Change
42% reduction in the number of concussions

25. …perhaps the pendulum has swung too far in the
direction of concussion phobia…
…“concussion” is not a single entity, and should be
replaced with the term “concussion spectrum”…

26. What We Don’t Know:
Concussion (biomechanical) thresholds and why they vary from
person to person
A specific age at which kids are safer to begin playing contact
sports
If playing contact sports for any number of years makes
someone more susceptible to neurodegenerative disease (MCI,
AD, CTE, etc.)

27. What We Think We Know:
Athletes are safer when coaches, parents and athletes understand
effective concussion recognition & response
Concussion education and state concussion laws are
working…There is NOT a concussion crisis or epidemic
Contact in youth sports should be minimized, but not eliminated
when it’s part of the game

29. Thank You
gus@email.unc.edu

30. SPORT CONCUSSION
SUMMIT
September 24, 2015#uminjuryctr