Concussion-Prevention Strategies Used in National Collegiate Athletic Association Divisions I and II Women's Soccer

This descriptive study was conducted via a questionnaire e-mailed to participants through Qualtrics (Provo, UT) survey software. The study was approved by the university's institutional review board. An informed consent form was included in the first page of the survey. Recruits were asked to continue only after reading and agreeing to the participation guidelines. Continuing to the survey questions was considered participant consent. All questions were optional, and participants could exit the survey at any time.

Inclusion criteria consisted of being a certified AT employed at an NCAA Division I or Division II university in the United States and considered the primary AT providing medical services to the university's women's soccer team. We chose NCAA universities because we perceived that this athletic conference had a greater likelihood of employing ATs who focused primarily on women's soccer. Division III schools were excluded due to the lack of athletic scholarships. A total of 334 NCAA Division I and 273 Division II universities in the United States had women's soccer teams. Potential participants' e-mail addresses were identified by reviewing publicly available information at the targeted universities' Web sites. If the women's soccer AT's e-mail address was not provided, we contacted the head AT for the university's athletic program to either obtain that contact information directly or forward the survey link to the appropriate AT. Of the 607 universities identified, e-mail contact information was obtained for 587 ATs. To increase response rates, we sent reminders at 2 and 4 weeks after the initial e-mail to those individuals who had yet to respond.

No survey instrument to evaluate current concussion-prevention methods and ATs' beliefs regarding these methods was available; therefore, we developed a survey for the current study. The survey instrument contained questions in 3 areas: (1) inclusion criteria, (2) current use of concussion-prevention strategies, and (3) ATs' beliefs in the effectiveness of proposed concussion-prevention strategies. Two close-ended questions screened for the inclusion criteria. Two close-ended questions evaluated current cervical-strengthening and headgear practices. The ATs who responded yes to current cervical strengthening were prompted to answer a follow-up question regarding how long this practice had been in place. The ATs who responded yes to current headgear use among their team were prompted to answer a follow-up question about the number of athletes using headgear. Three close-ended questions identified the ATs' beliefs in cervical strengthening, soccer headgear, and mouthguard use for concussion prevention. A question was also included to assess the clinicians' beliefs that mouthguards prevent concussions; this often-held idea in the athletic community is not evidence based.¹⁸  A final semistructured question provided ATs an opportunity to report any concussion-prevention practices not covered in the close-ended questions.

The first author (K.K.J.) developed the survey with consultation from a committee of experts, including an AT who had previously worked with elite-level women's soccer teams and a statistician. After development, the survey was reviewed by the committee of experts, was pilot tested, and underwent the Qualtrics system's evaluation of clarity and usability. Three pilot-testing participants were directed to give varying responses to evaluate the technical components of the survey (eg, branching questions). The survey consisted of a maximum of 10 questions, depending upon the respondent's previous answers. We projected that the survey instrument could be completed in less than 10 minutes.

Descriptive statistics of frequencies and percentages reported in the Qualtrics software system were used to interpret the results of the survey questions and were organized by responses. Each question was analyzed individually based on the number of responses.

This survey was sent to ATs at a total of 587 NCAA Division I and Division II schools. Responses were received from 245 ATs, for a response rate of 41.7%. Twenty-two (0.09%) participants did not meet the inclusion criteria and were excluded. Thus, 223 responses were recorded and analyzed. All questions were optional, so we calculated data and response rates for each question.

Survey results for the close-ended questions are presented in Table 1. The 78 ATs who indicated that a player on their team wore headgear were directed to a follow-up question asking for an estimate of the number of players who wore headgear. Text responses ranged from 1 to 25 players on a team. The number of players on their team who wore headgear was reported as 1 by 42 (53.85%) ATs, 2 by 20 (25.64%) ATs, 3 by 5 (6.41%) ATs, and 4 by 6 (7.69%) ATs. The wearing of headgear by 5, 6, 10, or 25 players was each reported by a single AT (1.28%).

The semistructured survey question, “Are any other concussion-prevention strategies being implemented within the women's soccer team at this time by you or a member of your staff?” was answered by 217 ATs. Respondents were allowed to select all options that applied and provide text explanations for 4 response options: (1) preventive equipment, (2) education on proper techniques to prevent concussions, (3) nutritional intervention, and (4) other. Despite the potential for redundancy in responses to the semistructured question and the previous close-ended questions, we evaluated the semistructured question independently. Results of the semistructured question, including text responses, are presented in Table 2. Of note, 7 of the 32 text responses that mentioned the use of soccer headgear as concussion-prevention equipment specifically described headgear use by athletes with a history of concussion. One AT noted that the player wearing headgear on the team was doing so at the recommendation of her physician.

We aimed to identify the strategies being used as concussion-prevention tools in NCAA Division I and Division II women's soccer programs and the ATs' beliefs regarding select interventions for concussion prevention. Areas of interest were cervical strengthening, use of soccer headgear, and mouthguards for the specific purpose of preventing concussion. With a response rate of 41.7%, our results provide an appropriate evaluation of concussion-prevention strategies in collegiate women's soccer players.

A cervical-strengthening program for concussion prevention had been implemented by 17.12% of respondent ATs' soccer teams. Of the 38 respondents who indicated the use of cervical strengthening, more than half (55.26%) stated that the program had been implemented within the past 2 years. The ATs had a high level (69.86%) of belief that cervical-strengthening and -stability programs would be effective in preventing concussions. However, with further analysis, we found that only 23 of the 153 individuals who reported belief in the efficacy of such programs were working with teams that actually implemented cervical strengthening. It is interesting that a large proportion of ATs believed a cervical-strengthening program would aid in preventing concussions, yet they were not using such a program. Cervical-strengthening programs entail minimal risk, and programs as short as 8 weeks have been shown to increase strength and decrease head velocity.¹⁹  However, the influence of cervical strengthening on concussion rates remains inconclusive and could be sport dependent. Previous researchers^13,20  observed that neck strength was not associated with concussion rates in contact sports. However, authors^{15,16,21–23}  have offered emerging evidence supporting the use of cervical strengthening in female soccer players for preventing concussion. Sex-based differences in neck strength may contribute to the elevated concussion rates in female soccer players, given that those with weaker overall neck strength appeared to be at a higher risk of concussion.¹⁶  Greater neck strength and anticipatory cervical muscle activation has been associated with a reduction in the head's kinematic response to external force,^21,22  which may aid in concussion prevention. Females displayed greater head-neck segment peak angular acceleration and displacement than their male counterparts, even though they exhibited earlier muscle activation than males.²³  In adolescent female soccer athletes, neck strength and header acceleration were significantly negatively correlated: those with weaker necks endured greater impacts during heading.¹⁵  In addition, Bretzin et al²¹  determined that soccer players with greater neck strength had decreased linear head accelerations. Although further investigations are necessary to fully evaluate the influence of neck strength on concussion rates, based on our findings, implementation of neck-strengthening protocols in women's soccer seem to be an emerging practice. However, a disconnect remains between ATs' belief in cervical strengthening and the implementation of such programs.

Due to soccer headgear being marketed for concussion prevention, the prevalence of its use by NCAA Division I and Division II women's soccer teams is of interest. More than one third of the ATs reported an athlete on their team wore some form of headgear; the number of athletes per team who wore headgear ranged from 1 to 25 players. Most ATs noted 1 (53.85%) or 2 (25.64%) players using headgear. A disconnect between ATs' beliefs and implementation was found regarding headgear as well. Although 35.94% of respondents said that a player used headgear, only 8.76% believed that headgear would prevent concussions. This low level of confidence in headgear for preventing concussions is likely a response to the inconclusive literature.^5–7,11,12  Whereas a single retrospective survey showed that not wearing headgear was associated with a 2.65 times greater relative risk of concussion than wearing headgear, the study lacked validity due to a lack of randomization and the researchers' reliance on athlete recall of the diagnosis.¹²  In a more recent study,¹¹  headgear had no influence on concussion rate or severity. Authors^5,7,10,24  of systematic reviews and position statements have stressed that research remains inconclusive on the effect of headgear on concussion risk, and limited evidence supports the use of headgear in preventing concussion. In addition, the mechanical properties of headgear may not mitigate impact attenuation during simulated soccer heading.²⁵  Biomechanical evaluations suggested that headgear could actually put athletes at a greater risk for concussion.⁹  Responses to the open-ended items regarding the use of protective equipment indicated that some athletes wore headgear specifically because of a history of concussion. Respondents provided the following information: “Previous athletes with history of 2+ concussions are required to wear protective headwear to help prevent another concussion from occurring”; “Headgear for girls with a previous concussion”; “a few players wear protective headgear due to previous concussions.” Based on our findings, ATs' beliefs appeared to be in line with research evidence regarding headgear, but athletes' beliefs might not align; a third of teams had only 1 athlete each using headgear. Further research is necessary to provide ATs with more definitive evidence for educating patients, particularly those with a history of concussion, on headgear's ability to prevent concussion (or lack thereof).

Another area of disconnect from the available evidence was mouthguard use for concussion prevention. We found that 20.7% of respondents believed that mouthguards would prevent concussion in soccer players, yet no evidence supports this.^5,7,10,26  Furthermore, a sports dentistry consensus statement²⁷  stated that mouthguards had not been shown to reduce head impacts. The use of mouthguards should be encouraged to prevent dental and oral injuries, but the evidence does not support their use for preventing concussions.^10,27  The fact that more ATs (20.7% versus 8.76%) believed in mouthguards than in headgear reflects a disconnect between ATs' beliefs and the available evidence.

Based on our results from the semistructured question, we identified additional concussion-prevention techniques. Several unique nutritional concussion-prevention strategies were being used, with omega-3 fatty acids mentioned the most. Although researchers²⁸  have shown omega-3 fatty acids offer some benefits for overall brain development and function, additional work is needed to understand omega-3′s role in concussion prevention as well as recovery. Brain Armor Supplement (Brain Armor Inc, Brookfield, WI) was a cited preventive nutritional strategy. This supplement is a plant-based docosahexaenoic acid omega-3 supplement derived from algae and marketed as promoting brain, eye, and heart health.²⁹  N-acetyl-cysteine use was also reported; it has antioxidant-based anti-inflammatory properties proposed to aid in immune function and cardiovascular health.³⁰  N-acetyl-cysteine reduced³¹  symptom severity in military members after a blast-induced mild traumatic brain injury. However, the translation of findings from individuals in an active combat zone to athletes remains to be evaluated. Researchers³²  studying other nutritional and pharmacologic interventions have suggested evidence is insufficient to support or refute the use of substances identified in the current study. Nutritional interventions are an emerging area in concussion prevention³³  and a potential area of focus for future investigation.

When designing this study, we considered possible restrictions and minimized them where possible. Nevertheless, limitations of this study design include the time constraints of data collection and the validity of the results. Data were collected over a period of 5 weeks, but additional findings might have been evident if collection had been extended. Survey methods create difficulty in drawing cause-and-effect conclusions, which limits the validity of results. It is also difficult to determine the accuracy of the results, because the answers were self-reported by supervising ATs. Self-reporting permits imprecise responses to occur. Another limitation affected the design of the survey questions. When ATs were asked if they believed a preventive method would be successful, binary responses of yes or no were the only options, and the respondents were not given an option of unsure. This binary response may have forced participants into providing an answer they did not honestly believe. However, answering all questions was optional, and respondents could choose to not answer. Participants' demographic information was not requested in the survey instrument. Information on years of certification, years of experience working with female soccer teams, and continuing education methods used would have provided insight into the observed disconnect among practice, beliefs, and available evidence. Future studies are needed to evaluate knowledge transfer from research findings to ATs' clinical practice. We targeted ATs who provided medical care to women's soccer teams at NCAA Division I and Division II universities. Although we selected this population due to female soccer players' increased concussion rates when compared across sports and by sex, the ability to translate these findings to other populations is limited. Whether training practices and concussion-prevention strategies differ in women's and men's collegiate soccer programs is unknown. We decided to focus on the use of neck strengthening and soccer headgear for preventing concussion; however, we acknowledge that these interventions may have other uses, such as heading-performance benefits or the potential for minimizing the effects of repeated subconcussive impacts from soccer heading.

Based on our findings, we recognized a disconnect between neck strengthening and headgear use as concussion-prevention strategies currently implemented in NCAA Division I and Division II women's soccer, ATs' beliefs in these tools, and the conclusions that can be drawn from the available literature. Whereas nearly 70% of ATs believed that cervical-strengthening programs would aid in concussion prevention, these programs were rarely used. Less than a fifth of respondents reported that cervical-strengthening or stability programs had been implemented for their women's soccer team. In contrast, more than one third of the respondents indicated use of headgear by at least 1 member of the team, yet more than 90% of ATs did not believe headgear prevented concussion. The ATs' lack of confidence in headgear as a concussion-prevention tool stemmed from the available literature. Given this disconnect between headgear use and ATs' beliefs, which were evidence based, we see a need for greater patient education. A surprising finding was that 20% of responding ATs believed that mouthguards prevented concussions. In addition, a wide range of nutritional interventions were used. Overall, future research must be performed before we can draw any conclusions about concussion-prevention strategies. Given the findings of this survey, we suggest that much progress needs to be made regarding the applications of the research, first to clinical beliefs and then to actual patient implementation.