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What are the most effective risk-reduction strategies in sport concussion?
  1. Brian W Benson1,
  2. Andrew S McIntosh2,
  3. David Maddocks3,4,
  4. Stanley A Herring5,
  5. Martin Raftery6,
  6. Jiří Dvořák7
  1. 1Department of Clinical Neurosciences, Faculty of Medicine, and Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  2. 2Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Monash Injury Research Institute, Monash University, Monash, Australia
  3. 3Perry Maddocks Trollope Lawyers, Melbourne, Australia
  4. 4Centre for Health Exercise and Sports Medicine, The University of Melbourne, Melbourne, Australia
  5. 5Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, and Team Physician, Seattle Seahawks and Seattle Mariners, Seattle, Washington, USA
  6. 6International Rugby Board, New South Wales, Australia
  7. 7Department of Neurology, Schulthess Clinic Zurich, Zurich, Switzerland
  1. Correspondence to Dr Brian W Benson, Department of Clinical Neurosciences, Faculty of Medicine, and Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, 2500 University Drive N.W., Calgary, Alberta, Canada, T2N 1N4; bbenson{at}


Aim To critically review the evidence to determine the efficacy and effectiveness of protective equipment, rule changes, neck strength and legislation in reducing sport concussion risk.

Methods Electronic databases, grey literature and bibliographies were used to search the evidence using Medical Subject Headings and text words. Inclusion/exclusion criteria were used to select articles for the clinical equipment studies. The quality of evidence was assessed using epidemiological criteria regarding internal/external validity (eg, strength of design, sample size/power, bias and confounding).

Results No new valid, conclusive evidence was provided to suggest the use of headgear in rugby, or mouth guards in American football, significantly reduced players’ risk of concussion. No evidence was provided to suggest an association between neck strength increases and concussion risk reduction. There was evidence in ice hockey to suggest fair-play rules and eliminating body checking among 11-years-olds to 12-years-olds were effective injury prevention strategies. Evidence is lacking on the effects of legislation on concussion prevention. Equipment self-selection bias was a common limitation, as was the lack of measurement and control for potential confounding variables. Lastly, helmets need to be able to protect from impacts resulting in a head change in velocities of up to 10 and 7 m/s in professional American and Australian football, respectively, as well as reduce head resultant linear and angular acceleration to below 50 g and 1500 rad/s2, respectively, to optimise their effectiveness.

Conclusions A multifactorial approach is needed for concussion prevention. Future well-designed and sport-specific prospective analytical studies of sufficient power are warranted.

  • Athletics
  • Concussion
  • Epidemiology
  • Head Injuries
  • Injury Prevention

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