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What strategies can be used to effectively reduce the risk of concussion in sport? A systematic review
  1. Carolyn A Emery1,
  2. Amanda M Black1,
  3. Ash Kolstad1,
  4. German Martinez1,
  5. Alberto Nettel-Aguirre1,
  6. Lars Engebretsen2,3,4,
  7. Karen Johnston5,6,
  8. James Kissick7,8,9,
  9. David Maddocks10,
  10. Charles Tator11,12,
  11. Mark Aubry13,14,15,
  12. Jiří Dvořák16,17,
  13. Shinji Nagahiro18,
  14. Kathryn Schneider1
  1. 1 Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada
  2. 2 Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
  3. 3 Oslo Sports Trauma Research Center, Oslo, Norway
  4. 4 Medical and Scientific Department, International Olympic Committee (IOC), Lausanne, Switzerland
  5. 5 Division of Neurosurgery, University of Toronto, Ontario, Canada
  6. 6 Concussion Management Program Athletic Edge Sports Medicine, Ontario, Canada
  7. 7 Carleton University Sport Medicine Centre, Ontario, Canada
  8. 8 Department of Family Medicine, University of Ottawa, Ontario, Canada
  9. 9 International Paralympic Committee Medical Committee
  10. 10 Perry Maddocks Trollope Lawyers
  11. 11 Canadian Concussion Centre, Toronto Western Hospital, University Health Network, Ontario, Canada
  12. 12 Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
  13. 13 Ottawa Sport Medicine Centre, Ontario, Canada
  14. 14 International Ice Hockey Federation
  15. 15 IOC Medical Commission Games Group
  16. 16 Department of Neurology, University of Zurich, Zurich, Switzerland
  17. 17 Schulthess Clinic Zurich
  18. 18 Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
  1. Correspondence to Dr Carolyn A Emery, Sport Injury Prevention Research Centre, Faculty of Kinesiology and Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, 2500 University Dr. NW, Calgary, Alberta T2N1N4, Canada; caemery{at}


Aim or objective To examine the effectiveness of concussion prevention strategies in reducing concussion risk in sport.

Design Systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines.

Data sources Eleven electronic databases searched and hand-search of references from selected studies.

Eligibility criteria for selecting studies The following were the study inclusion criteria: (1) contained original human research data; (2) investigated an outcome of concussion or head impact; (3) evaluated a concussion prevention intervention; (4) included sport participants; (5) analytical study designand (6) peer-reviewed. The following were the exclusion criteria: (1) review articles, case series or case studies and (2) not in English.

Results The studies selected (n=48) provided evidence related to protective gear (helmets, headgear, mouthguards) (n=25), policy and rule changes (n=13) and other interventions (training, education, facilities) (n=10). Meta-analyses demonstrate a combined effect of a 70% reduction (incidence rate ratio (IRR)=0.3 (95% CI: 0.22 to 0.41)) in concussion risk in youth ice hockey leagues where policy disallows body checking, and the point estimate (IRR=0.8 (95% CI: 0.6 to 1.1)) suggests a protective effect of mouthguards in contact and collision sport (basketball, ice hockey, rugby).

Summary/conclusions Highlights include a protective effect of helmets in skiing/snowboarding and the effectiveness of policy eliminating body checking in youth ice hockey. Future research should examine mouthguards in contact sport, football helmet padding, helmet fit in collision sport, policy limiting contact practice in youth football, rule enforcement to reduce head contact in ice hockey and soccer, ice surface size and board/glass flexibility in ice hockey and training strategies targeting intrinsic risk factors (eg, visual training).

Systematic review registration PROSPERO 2016:CRD42016039162

  • concussion
  • prevention
  • sport Injury

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  • Contributors CAE was responsible for the conception and design of the systematic review, analysis and interpretation, drafting of the article, provided final approval and is the guarantor of the work; AMB contributed to the design of the systematic review, analysis and interpretation. AN-A conducted the meta-analyses and contributed to the interpretation. AMB, AK, CAE, GM contributed to the article search and selection process. AMB, AK, CAE, GM, KJ, LE, JK, DM, CT contributed to the risk of bias assessment. All authors contributed to the final systematic review plan (PROSPERO) and reviewed the article critically and provided final approval.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.