INJURY SURVIELLANCE IN YOUTH FOOTBALL Jillian Urban Hobson A thesis submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Masters of Public Health in the Public Health Leadership program in the Gillings School of Global Public Health. Chapel Hill 2018 Approved by: © 2018 Jillian Urban Hobson ALL RIGHTS RESERVED 1 ABSTRACT Injuries frequently occur in contact sports such as football, however injury risk in football is 5 to 7 times greater than other youth contact sports and 14% of all football injuries are serious. With over 3 million youth football players, there is a critical need to understand rates and common mechanisms of injury at this level. Therefore, the objective of this thesis was to complete a literature review of existing sports injury surveillance systems and conduct surveillance of injuries occurring in a local Winston Salem, NC youth football organization (ages 9-13) within a single season. This thesis highlights the role of injury surveillance in sports; need to conduct further surveillance efforts at the youth level; and value of combining surveillance efforts with on-field video collected during sporting events to investigate injury mechanisms in youth football. 2 ACKNOWLEDGEMENTS The National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2TR001421 supported Dr. Jillian Urban in the completion of this degree. Scott Proescholdbell, MPH (preceptor) and Dr. Karin Yeatts (advisor) provided guidance and mentorship throughout the practicum portion of this project. Dr. Steve Marshall provided guidance in the development of the data collection tools. Dr. Joel Stitzel and the iTAKL team supported the athletic trainer and on-field video data collection. Derek Jones, MS, Mireille Kelley, MS, & Tina Strates coordinated on-field coverage of video data. Ashley Donahue, LAT, ATC, MS and Erin Strouse, LAT, ATC, MS provided on-field athletic training coverage and completed the injury inquiry forms. William Flood served as secondary video verification. Sara Dalton, M.Ed., LAT, ATC (Datalys) provided technical support for Datalys database, although not used for the final analysis. 3 TABLE OF CONTENTS LIST OF TABLES .................................................................................................................................... 5 LIST OF FIGURES .................................................................................................................................. 6 LIST OF ABBREVIATIONS ................................................................................................................... 7 CHAPTER 1 – SPORTS INJURY SURVEILLANCE LITERATURE REVIEW ...................................... 8 Introduction ............................................................................................................................................... 8 Methods .................................................................................................................................................. 10 Analysis of Literature Review Findings ................................................................................................. 11 Overall Injury Rates ................................................................................................................................ 17 Concussion Injury Rates ......................................................................................................................... 20 Recommendations for Youth Football Surveillance ............................................................................... 23 CHAPTER 2 – PRACTICUM EXPERIENCE: INJURY SURVEILLANCE IN A YOUTH FOOTBALL LEAGUE .................................................................................................................................................... 26 Introduction ............................................................................................................................................. 26 Methods .................................................................................................................................................. 27 Results ..................................................................................................................................................... 29 Video Abstraction ................................................................................................................................... 33 Head and Neck Injury Case Review ....................................................................................................... 35 Discussion ............................................................................................................................................... 38 Lessons Learned and Future Work ......................................................................................................... 42 Appendix A. All Cases .......................................................................................................................... 44 Appendix B. Count of injuries evaluated by the athletic trainer by week for all levels of play and relevant events associated with each week. ............................................................................................ 45 Appendix C. Injury Inquiry Form ........................................................................................................... 46 Appendix D. Video Abstraction From .................................................................................................... 48 CHAPTER 3 – REFLECTION ON LEADERSHIP TRAINING ............................................................... 52 REFERENCES ........................................................................................................................................... 56 4 LIST OF TABLES Table 1. Purpose and population of each surveillance system evaluated in this study. ............................. 12 Table 2. Collegiate, high school, and youth football injury rates reported in the literature. Injury rates reported per 1,000 athlete-exposures (AE). Confidence intervals reported, if available. EDU = education only sub-group; HUF = Head's Up Football sub-group; N/A=custom surveillance system. ...................... 18 Table 3. Most frequent general and specific injury mechanisms at the collegiate and high school levels of football for all injuries. ............................................................................................................................... 19 Table 4. Common body region injured at the collegiate and high school levels of football. ...................... 19 Table 5. Collegiate, high school, and youth football concussion rates reported in the literature. Injury rates reported per 1,000 athlete-exposures (AE). Confidence intervals reported, if available. EDU = education only sub-group; HUF = Head's Up Football sub-group; N/A=custom surveillance system. ..... 21 Table 6. Most common general and specific injury mechanisms at the collegiate, high school, and youth levels of football for concussions................................................................................................................ 22 Table 7. Age and weight restrictions for the athletes evaluated in this study. Age is determined as of 7/31/17. Weight allowance for JPW and JM levels of play include a 5lb equipment allowance. 2 MM teams were followed in this study with 20 athletes on each team. O/L = older lighter. ............................. 27 Table 8. Number of injuries within each level of play that occurred during competitions from 8/12/2017- 11/12/2017 .................................................................................................................................................. 30 Table 9. Number of injuries within each level of play that occurred during practices from 8/1/2017- 11/12/2017 .................................................................................................................................................. 31 Table 10. Summary of injuries with complete video abstraction. ............................................................... 33 5 LIST OF FIGURES Figure 1. Flow diagram demonstrating the article selection process or the inclusion of studies in the systematic review. ....................................................................................................................................... 12 Figure 2. Injury, body region, and mechanism categories recorded in (a) RIO and (b) NCAA ISP and NATION. .................................................................................................................................................... 16 Figure 3. Competition injury rate per 1,000 AE by injury type and level of play. ..................................... 30 Figure 4. Competition injury count and injury rate each week for (A) Tiny Mite, Mighty Mite Silver, and Might Mite Blue; (B) Jr Pee Wee, 10U, 12U, and Jr Midget; and (C) All Levels of Play. ........................ 32 Figure 5. Speed of athletes involved in the injurious event. ....................................................................... 34 6 LIST OF ABBREVIATIONS AE Athlete-exposure RIO Reporting Information Online NCAA ISP NCAA ISP = National Collegiate Athletic Association Injury Surveillance Program NATION National Athletic Treatment, Injury, and Outcomes, Network NATA National Athletic Trainers Association AT Athletic trainer