{"id":6680,"date":"2019-11-15T06:30:57","date_gmt":"2019-11-15T12:30:57","guid":{"rendered":"http:\/\/thesportjournal.org\/?p=6680"},"modified":"2019-10-29T08:27:26","modified_gmt":"2019-10-29T13:27:26","slug":"concussions-in-cheerleaders-reported-from-a-countywide-concussion-injury-surveillance-system","status":"publish","type":"post","link":"https:\/\/thesportjournal.org\/article\/concussions-in-cheerleaders-reported-from-a-countywide-concussion-injury-surveillance-system\/","title":{"rendered":"Concussions in Cheerleaders Reported from a Countywide Concussion Injury Surveillance System"},"content":{"rendered":"\n

Authors:<\/strong> Luis Gude, MD, Gillian Hotz, PHD<\/p>\n\n\n\n

Corresponding Author:<\/strong>
Gillian Hotz Ph.D
Lois Pope LIFE Center \u2013 1-40, (R-48)
1095 NW 14th<\/sup> Terrace, Miami, Florida 33136
ghotz@med.miami.edu
305-243-4004<\/p>\n\n\n\n

Gillian A. Hotz, PhD is a research professor at the\nUniversity of  Miami, Miller School of<\/p>\n\n\n\n

Medicine and a nationally recognized behavioral\nneuroscientist and expert in pediatric and adult neurotrauma, concussion\nmanagement, and neurorehabilitation. Dr. Hotz is the director of the KiDZ\nNeuroscience Center, WalkSafe, BikeSafe, and SkateSafe programs, and has been\nco-director of the Miller School of Medicine\u2019s Concussion Program since 1995.\nShe continues to assess and treat many athletes from Miami-Dade County public\nand private high schools, the University of Miami, and from other colleges and\nthe community.<\/p>\n\n\n\n

Concussions in Cheerleaders Reported from a Countywide Concussion Injury Surveillance System<\/h3>\n\n\n\n

ABSTRACT<\/strong><\/p>\n\n\n\n

The purpose of this study was to\nadvocate for the acceptance of cheerleading as a sport so that its athletes are\neligible for the same resources available to other sports, such as concussion\neducation programs and injury surveillance systems. The subjects of this study\nwere cheerleaders from Miami Dade County public high schools who sustained a\nsports related concussion (SRC) from August 2015 to June 2019, identified from\nthe Miami Concussion Model Concussion Injury Surveillance System. The database\nis compiled from reports submitted by certified athletic trainers after a\nsuspected concussion, from post-injury ImPACT tests, and from patients who\npresent to the University of Miami Sports Concussion Clinic for evaluation. A\ntotal of 29 cheerleaders were identified. The 2018-19 academic year accounted\nfor 45% of reported concussions, representing a large increase in number\ncompared to previous years. This was observed after increased emphasis was\nplaced on certified athletic trainers to report SRC in cheerleaders. On average\ncheerleaders with SRC were withheld from sport for 26.2 days, and 38% had\nprolonged recovery of >28 days. Cheerleaders perform complex athletic\nmaneuvers that put them at risk of injury, particularly SRC. If considered a sport,\ncheerleading would be afforded the same benefits as other sports, including\nresources for better facilities, mandatory concussion education, ATC\navailability, baseline neurocognitive testing, and inclusion in injury\nsurveillance systems. Increased knowledge of the long-term sequelae of\nconcussions and repetitive head injuries has led to the development of\nconcussion education programs and injury surveillance systems to protect\nathletes from these types of injuries. Although competitive cheerleading has\nbeen recognized as a sport, cheerleading as a whole has not, putting its\nathletes at risk as its participants are not included in these safety programs.  <\/p>\n\n\n\n\n\n\n\n

Key words:<\/strong> Concussions, Cheerleading, Player\nSafety, Education<\/p>\n\n\n\n

INTRODUCTION<\/strong><\/p>\n\n\n\n

Cheerleading has its origins in the\nlate 1800s. Originally an all-male activity that consisted of leading cheers in\nsupport of their team, cheerleading has undergone many changes to become the\nteam based athletic activity as it is currently known. Now dominated by female\nathletes, cheerleading includes acrobatic maneuvers such as stunts meant to\nentertain and encourage spectators to cheer for their team, or to compete as a\nsport in areas where it is recognized (9). It is estimated that 3.8 million\nchildren ages 6 and older participated in cheerleading in 2016 in the United\nStates, increased from 3.2 million in 2007 (1). Children as young as 3 years old\nmay join squads that are often associated with youth football teams.\nCheerleading has also spread globally, and was given provisional recognition as\na sport by the International Olympic Committee in 2016 with 116 national\nfederations as members (11).<\/p>\n\n\n\n

With the increase in participation\nand complexity of modern cheerleading activities, there has also been an\nincrease in the number and rate of cheerleading injuries. Using the National\nElectronic Injury Surveillance System, Naiyer et al. (16) estimated that the number of\ncheerleading injuries increased by 242% from 1990 to 2012, and that from 2001\nto 2012 the rate of concussion or closed head injury increased by 290% in\nchildren aged 5 to 18 years. Lincoln et al. (12) reported similar findings, with a\n26% mean annual increase in the number of concussions in cheerleaders in a\npublic high school system from 1997 to 2008. Despite having a low rate per\nathletic exposure compared to other sports, sports related concussions (SRC)\nare a common injury in cheerleading, accounting for 4-30% of all cheerleading\ninjuries (7,\n12, 18, 21).<\/p>\n\n\n\n

The topic of whether or not\ncheerleading is a sport has been a subject of debate. A study of collegiate\ncheerleaders showed that its participants have fitness levels equivalent to\nthose participating in other sports such as basketball and tennis (17). Despite the recognition that great\nskill and athleticism is required to participate in cheerleading, some still do\nnot consider cheerleading a sport as there is no direct competition. This has\nled to the development of teams that focus on competition, such as competitive\nspirit or STUNT, which has complicated the discussion as cheerleaders in\nnon-competitive squads may still be performing the same maneuvers as those in\ncompetitive teams but without the same safety measures in place. In 2012, the\nAmerican Association of Pediatrics (AAP) called for the recognition of\ncheerleading as a sport given the athleticism required to participate in and\nthe risk of injury associated with modern cheerleading (6).<\/p>\n\n\n\n

In response to the growing national\nawareness of SRC in athletes, a comprehensive concussion management team formed\nat the University of Miami in 2012. In collaboration with the Miami-Dade County\n(MDC) Public School Athletics Department, this team developed the Countywide\nConcussion Program (CCP) with the goals of reducing the incidence and improving\nthe management of SRC. The CCP focuses on training and education to increase\nawareness and identification of SRC, and includes a Concussion Injury\nSurveillance System (CISS). Since 2012, the CCP has been implemented in all 35\nMDC Public High Schools and is mandatory for contact sports (10). Each high school is required to\nhave a certified athletic trainer (ATC) on staff to manage the CCP at that\nschool.<\/p>\n\n\n\n

The Greater Miami Athletic Conference\n(GMAC), which oversees public high school athletic activities in MDC, has not\nrecognized cheerleading as a sport and therefore it is not mandated that\ncheerleaders are included in the CCP. However, the ATC of each high school are\nencouraged to consider cheerleading a sport at yearly concussion education and\ntraining workshops, and to include its athletes in the CCP. The purpose of this\nstudy was to report on SRC sustained by cheerleaders in MDC public high schools\ncaptured by the CISS, and to advocate for the acceptance of cheerleading as a\nsport so that its athletes may benefit from the same resources that other\nsports receive and inclusion in concussion management protocols. <\/p>\n\n\n\n

METHODS<\/strong><\/p>\n\n\n\n

The\nsubjects of this study were cheerleaders from the 35 MDC public high schools\nwho sustained a SRC from August 2015 to June 2019 and were identified from the\nCISS database. The database is compiled from ImPACT test results and two REDCap\ndatabases. ImPACT is a computer-based neurocognitive assessment used in\nbaseline testing and then again when an athlete is suspected of having\nsustained a SRC. Under the CCP all athletes participating in contact sports are\nrequired to perform a baseline ImPACT test, and it is recommended that any\nathlete suspected of having a SRC undergo post-injury testing. REDCap is a\nweb-based application used to capture data for clinical research and to create\ndatabases. The first REDCap system is generated from reports submitted by the\nATC of each of the MDC public high schools. This 33 data point report is\nsubmitted once an athlete who has sustained a SRC has been cleared by a\nphysician or is otherwise lost to follow-up. The second REDCap database is\ngenerated by the University of Miami Sports Concussion Clinic research staff\nwho input information of patients who present to the concussion clinic for\nevaluation. The CCP and CISS are described in detail by Hotz et al. (10). Subjects who attended high school\nin a different county or private or charter schools were excluded from this\nstudy. Approval for this study was obtained from the Miami-Dade County Public\nSchool Department of Athletics and University of Miami Institutional Review\nBoard. <\/p>\n\n\n\n

RESULTS<\/strong><\/p>\n\n\n\n

A total of 29 cheerleaders with SRC\nwere identified, 28 females and 1 male. The average age was 16 years, with\njuniors (46%) and seniors (29%) sustaining the most SRC. There was a large\nincrease in the number of reported SRC in the 2018-19 academic year in\ncomparison to previous years. Demographic information is reported in Table 1. <\/p>\n\n\n\nTable 1:<\/strong> Demographics Data\n\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n
 <\/strong><\/td>\n N<\/strong><\/td>\n %<\/strong><\/td>\n <\/tr>\n
All<\/strong><\/td>\n 29<\/td>\n 100%<\/td>\n <\/tr>\n
Age<\/strong> (mean, years)<\/td>\n 16<\/td>\n  <\/td>\n <\/tr>\n
School Year<\/strong><\/td>\n  <\/td>\n  <\/td>\n <\/tr>\n
Freshman<\/td>\n 2<\/td>\n 8%<\/td>\n <\/tr>\n
Sophomore<\/td>\n 4<\/td>\n 17%<\/td>\n <\/tr>\n
Junior<\/td>\n 11<\/td>\n 46%<\/td>\n <\/tr>\n
Senior<\/td>\n 7<\/td>\n 29%<\/td>\n <\/tr>\n
Race\/Ethnicity<\/strong><\/td>\n  <\/td>\n  <\/td>\n <\/tr>\n
Black<\/td>\n 5<\/td>\n 17%<\/td>\n <\/tr>\n
Hispanic<\/td>\n 18<\/td>\n 62%<\/td>\n <\/tr>\n
White <\/td>\n 2<\/td>\n 7%<\/td>\n <\/tr>\n
Other*<\/td>\n 4<\/td>\n 14%<\/td>\n <\/tr>\n
Gender<\/strong><\/td>\n  <\/td>\n  <\/td>\n <\/tr>\n
Female<\/td>\n 28<\/td>\n 97%<\/td>\n <\/tr>\n
Male<\/td>\n 1<\/td>\n 3%<\/td>\n <\/tr>\n
Academic Year of Injury<\/strong><\/td>\n  <\/td>\n  <\/td>\n <\/tr>\n
2015-16<\/td>\n 4<\/td>\n 13%<\/td>\n <\/tr>\n
2016-17<\/td>\n 6<\/td>\n 19%<\/td>\n <\/tr>\n
2017-18<\/td>\n 5<\/td>\n 16%<\/td>\n <\/tr>\n
2018-19<\/td>\n 14<\/td>\n 45%<\/td>\n <\/tr>\n
*Other includes unknown race or ethnicity, non-hispanics with unknown race, non-hispanic Asians, & Haitians <\/td>\n <\/tr>\n <\/tbody>\n<\/table>\n\n\n\n

Most of the SRC were sustained at practice (28), except for 1 at a school\nperformance. From the data reported, 10 cheerleaders were either bases or\nspotters and 7 were flyers. Of the 29 subjects identified, 21 (72%) were\ncleared for return-to-play with an average time withheld from sport of 26 days,\n8 (38%) of which had a prolonged recovery of >28 days. Eight (28%) subjects\nwere lost to follow-up (See Table 2).<\/p>\n\n\n\nTable 2:<\/strong> Description of Sample\n\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n
 <\/strong><\/td>\n N<\/strong><\/td>\n %<\/strong><\/td>\n <\/tr>\n
History of Concussion<\/strong><\/td>\n  <\/td>\n  <\/td>\n <\/tr>\n
No<\/td>\n 16<\/td>\n 94%<\/td>\n <\/tr>\n
Yes<\/td>\n 1<\/td>\n 6%<\/td>\n <\/tr>\n
Event<\/strong><\/td>\n  <\/strong><\/td>\n  <\/strong><\/td>\n <\/tr>\n
Performance<\/td>\n 1<\/td>\n 4%<\/td>\n <\/tr>\n
Practice<\/td>\n 24<\/td>\n 96%<\/td>\n <\/tr>\n
Position<\/strong><\/td>\n  <\/strong><\/td>\n  <\/strong><\/td>\n <\/tr>\n
Base or Spotter<\/td>\n 10<\/td>\n 59%<\/td>\n <\/tr>\n
Flyer <\/td>\n 7<\/td>\n 41%<\/td>\n <\/tr>\n
Academic Accommodations <\/strong><\/td>\n  <\/td>\n  <\/td>\n <\/tr>\n
No<\/td>\n 5<\/td>\n 33%<\/td>\n <\/tr>\n
Yes<\/td>\n 10<\/td>\n 67%<\/td>\n <\/tr>\n
Time out of play <\/strong>(days)*<\/strong><\/td>\n  <\/td>\n  <\/td>\n <\/tr>\n
Mean (SD)<\/td>\n 26.2 (15.7)<\/td>\n <\/tr>\n
Median (25th%, 75th%)<\/td>\n 22 (14, 36)<\/td>\n <\/tr>\n
Minimum, maximum<\/td>\n 7, 59<\/td>\n <\/tr>\n
* Measured by days from date of concussion until date cleared by clinician.
\nSD=Standard deviation <\/td>\n <\/tr>\n<\/tbody>\n<\/table>\n\n\n\n

DISCUSSION<\/strong><\/p>\n\n\n\n

Our findings show that cheerleaders\nin their junior and senior year sustained the majority of SRC in this\npopulation, which may be due to these upperclassmen having more experience in\nthe sport and therefore participate in complex maneuvers that put them at\nhigher risk of injury. Prior to the start of 2018-19 academic year, CCP staff\nplaced increased emphasis on the importance of reporting SRC in cheerleaders to\nATC during their yearly training workshop. Subsequently there was a large\nincrease in the reported number of injuries compared to previous years,\naccounting for 45% of reported SRC in this study. Our findings are similar to\nthose of other studies that have shown that the highest number of injuries to\ncheerleaders occur at practice (7,\n16, 18, 22), and that bases and spotters sustain\nmore SRC than flyers (20).<\/p>\n\n\n\n

It is estimated that between 1 and\n1.9 million SRC occur per year in US children aged less than 18 years, and that\nthe majority of these patients are not seen in health care settings (4). Identifying a SRC when it occurs is\ncrucial, not only so that it may be managed properly, but also to reduce the\nrisk associated with repetitive head injuries. Individuals with SRC experience\na wide variety of physical, cognitive, and emotional symptoms that can decrease\nquality of life and interfere with normal daily activities (8,\n24). Academic accommodations, such as\ncurriculum and environmental adjustments, are typically recommended to help the\nstudent return to pre-concussion performance levels (14). In this report, 67% of cheerleaders\nreceived academic accommodations. <\/p>\n\n\n\n

Most adolescents with SRC typically\nrecover within 2 weeks post injury (3, 8,\n13, 26). Reports of the percent of children\nwith concussion who develop persistent post-concussive symptoms lasting over 28\ndays has varied greatly, from 1.5% in high school athletes (15) to 31% of children presenting to pediatric emergency departments within the Pediatric Emergency\nResearch Canada network (25). Those\nwith prolonged recovery of over 30 days are at increased risk of long-term\nsequelae such as anxiety, and mood and behavior disorders (3). Compared to males, female patients\nwith concussion report higher symptom burden, take longer to return to\nbaseline, and are more likely to have symptoms persist for over 30 days (5,\n19, 25, 26). In a review of the National High\nSchool Sports-Related Injury Surveillance Study, Currie et al. (7) noted that cheerleading accounted\nfor the second highest proportion of injuries that led to a time loss of over 3\nweeks or medical disqualification from sport. In addition, cheerleading\naccounts for 65% of catastrophic sports related injuries in females (2). In our report, cheerleaders were\nwithheld from sport for an average of 26 days, and 38% of cheerleaders who were\ncleared for return to play had a prolonged recovery of over 28 days. These\nfindings suggest that the injuries, including concussions, that cheerleaders\nsustain may be more severe when compared to other sports (7). <\/p>\n\n\n\n

Limitations<\/strong><\/p>\n\n\n\n

The major limitations of this study\nstem from the methods by which SRC in cheerleaders are reported in MDC. Through\nthe CCP, ATCs are responsible for the data input of SRC in multiple sports.\nSince cheerleading is not considered a sport by GMAC, monitoring under the CISS\nis not mandatory and the ATC relies on the coaches or athlete to report an\nevent. These injuries are underreported to the ATC as they may not be present\nat practices or other events, and it is not mandated that the athlete obtains\nreturn-to-play clearance. This likely contributed to the high number (8, 28%)\nof cheerleaders lost to follow-up in this report. The CISS does not capture\nathletes with SRC who presented to facilities outside of the University of\nMiami Sports Concussion clinic, such as pediatricians, emergency departments,\nor urgent health centers, unless the ATC submitted the surveillance report.\nAccurate reporting of SRC in cheerleading would help bolster the argument on\nthe importance of making cheerleading a sport. It could also identify athletic\nprograms with high numbers of SRC and target them for improvement. <\/p>\n\n\n\n

Currently the CISS contains entries\nspecific for cheerleading, however these are often left unanswered by the ATCs\nleading to incomplete data sets. The data collected through the CISS could be\nimproved by providing information on cheerleading positions and routines to ATC\nduring their yearly protocol training sessions, and by adding sections that\ndetail the mechanism of injury, including the maneuver being performed, fall\nheight, and type of surface (23). This information could help\nidentify high-risk activities and guide future rule changes to protect\ncheerleaders. <\/p>\n\n\n\n

CONCLUSIONS<\/strong><\/p>\n\n\n\n

Cheerleaders perform complex athletic\nmaneuvers that put them at risk of injury, particularly SRC. Our findings\nsupport the stance of the AAP on the importance of recognizing cheerleading as\na sport. If considered a sport, cheerleading would be afforded the same\nbenefits as other sports, including resources for better facilities, mandatory\nconcussion education, ATC availability, baseline neurocognitive testing, and\ninclusion in injury surveillance systems. Future studies should monitor and\ntrack SRC and other injuries in cheerleading to improve safety and to advance\nregulations and policies in this sport. Additional research is required to\ncompare the sporting activities and injuries of cheerleaders in competitive and\nnon-competitive squads. <\/p>\n\n\n\n

APPLICATIONS IN SPORT<\/strong><\/p>\n\n\n\n

Increased knowledge of the long-term sequelae of concussions and repetitive head injuries has led to the development of concussion education programs and injury surveillance systems to protect athletes from these types of injuries. Although competitive cheerleading has been recognized as a sport, cheerleading as a whole has not, putting its athletes at risk as its participants are not included in these safety programs. \u00a0<\/p>\n\n\n\n

ACKNOWLEDGMENTS<\/strong><\/p>\n\n\n\n

The authors would like to thank the UHealth\nSports Medicine Institute, the Miami-Dade County School Board Athletics\nDepartment, and all the Miami-Dade County Certified Athletic Trainers. We would\nalso like to thank the Goldstein Family for their continued support of the\nCountywide Concussion Program. <\/p>\n\n\n\n

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Hotz, PhD is a research professor at the University Of Miami Miller School Of Medicine and a nationally\u2026","rel":"","context":"In "Research"","img":{"alt_text":"Table 1","src":"https:\/\/i0.wp.com\/thesportjournal.org\/wp-content\/uploads\/2018\/04\/Table1.png?resize=350%2C200","width":350,"height":200},"classes":[]},{"id":7817,"url":"https:\/\/thesportjournal.org\/article\/increased-identification-of-concussions-in-high-school-wrestlers-after-rule-change\/","url_meta":{"origin":6680,"position":1},"title":"Increased Identification of Concussions in High School Wrestlers after Rule Change","date":"March 5, 2021","format":false,"excerpt":"Authors: Luis Gude, MD, Gillian Hotz, PHD Corresponding Author:Gillian Hotz Ph.DLois Pope LIFE Center \u2013 1-40, (R-48)1095 NW 14th TerraceMiami, Florida 33136.ghotz@med.miami.edu305-243-4004 Gillian A. 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