A Model of Prevention of Sports Concussion in Adults

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Chuling Lo, Ph.D.1 and Bess Sirmon-Taylor, Ph.D.1

ABSTRACT

This article discusses the definitions of prevention and presents a model that addresses multidimensional aspects of sports concussion prevention from the perspectives of epidemiology, education, environmental modification, enforcement, and evaluation. Epidemiology is helpful in identifying the incidence of concussion and the interventions most likely to reduce its occurrence. Education ensures that accurate information on concussion is communicated to stakeholders. Modifications in the physical and sociocultural environments may lessen the potential for injury and reduce the risk of concussion. Enforcement of legislation standards can be effective in concussion prevention, especially at the preinjury and injury phases. The evaluation dimension assesses the effectiveness of prevention programs and guides future program development. This five-E model explains concussion prevention as a recursive loop process. Each dimension is closely associated in the prevention of sports concussion. KEYWORDS: Sports concussion, prevention, five-E

Learning Outcomes: As a result of this activity, the reader will be able to (1) define the scope and practice of prevention; (2) explain the application of epidemiology in concussion prevention; (3) discuss the content of concussion education for different stakeholders; (4) explain the impact of social milieu in sports concussion; (5) discuss the possible ideas for future sports concussion prevention.

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Department of Rehabilitation Sciences, The University of Texas at El Paso, El Paso, Texas. Address for correspondence: Chuling Lo, Ph.D., Department of Rehabilitation Sciences, The University of Texas at El Paso, 500 West University Drive El Paso, TX 79902 (e-mail: [email protected]). Concussion 101 for SLPs; Guest Editor, Anthony P. Salvatore, Ph.D., CCC-SLP

Semin Speech Lang 2014;35:211–220. Copyright # 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. DOI: http://dx.doi.org/10.1055/s-0034-1384683. ISSN 0734-0478.

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EPIDEMIOLOGY, EDUCATION, ENVIRONMENTAL MODIFICATION, ENFORCEMENT, EVALUATION The classic epidemiological triad of host, agent, and environment can provide a perspective for discussing concussion prevention. According to this schematic, the occurrence of concussion can be described as an interaction between host (athletes), agent (sports), and environment (physical and sociocultural).1 In addition, Tator proposed five Es in prevention of sports concussion: epidemiology, education, engineering, enforcement, and evaluation.2 Incorporating Tator’s five-E model and epidemiological triad, this article presents a model of concussion prevention, replacing engineering with environmental modification, to address the impact of the sociocultural milieu along with physical environment, in the prevention of sports concussion. This article discusses each dimension by its definition, goals, approaches, and outcomes. Each dimension addresses the issue of concussion prevention either by the role of host (athletes), sports as agent, or the environment that influences the outcomes of prevention.

EPIDEMIOLOGY IN CONCUSSION PREVENTION Definition and Goals “Epidemiology is the study of the distribution and determinants of health-related states and events in specified populations and the application of this study to the control of health problems.”1(p.47) Therefore, epidemiology is helpful in identifying the incidence of concussion and the interventions most likely to reduce its occurrence. It is also helpful in targeting the interventions at the populations at greatest risk.1 There are two types of epidemiological studies. Descriptive studies are useful in identifying the distribution of concussion according to a specific cause (such as sports) and/or demographic characteristics of concussion victims. These studies identify characteristics of athletes who suffer from concussions, geographic hot spots where concussions occur more often, and particular sports in which concussion rates exceed statewide or national

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averages.1 Analytic studies are helpful in determining the exposure to factors that may increase or decrease the risk of concussion, and thus are helpful in preventing the occurrence of concussion.

Approach and Examples To identify the distribution of concussion and demographic characteristics of those who suffer a concussion, there is a need to establish injury surveillance databases for tracking incidence and prevalence of concussion. Surveillance information is important for two reasons. First, it provides a true understanding of injury types and mechanism, which is useful in defining priorities, allocating resources, and planning for prevention programs. Second, surveillance can define the burden and risk associated with different sports. People can make a decision on the sports they play, according to the relative safety.3 Several injury surveillance systems have been developed for this reason. For example, the National Collegiate Athletic Association (NCAA) has maintained the Injury Surveillance System (ISS) for intercollegiate athletics since 1982 and has provided current and reliable data describing injury trends in intercollegiate sports in Division I, II, and III NCAA schools. ISS data are reviewed by NCAA sport rules and sports medicine committees to provide a foundation for evidence-based decision making with regard to health and safety issues.4 However, this surveillance system does not follow club, intramural, or recreational athletes in the college setting.3 Another limitation is that participation in the NCAA ISS is voluntary. Thus, the accuracy of the data relies on collegiate athletic trainers’ active reports.5 The National Athletic Trainers Association provides concussion rates for high school athletes. High School Reporting Information Online (RIO) is the Internet-based data collection tool used in the National High School Sports-Related Injury Surveillance Study. This study was first implemented during the 2005 to 2006 academic year and is currently the only surveillance study of all time loss injuries and a national sample of U.S. high school athletes.3 Approximately 100 high schools across the

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country currently participate annually. Using certified athletic trainers as data reporters, High School RIO records describe rates, patterns, and trends of high school sport-related injuries throughout the academic year.3 Other surveillance systems include the Fairfax County Public School System Injury Surveillance Database, comprising over 10 years of cumulative data from 25 high schools in Fairfax County, Virginia. The National Center for Catastrophic Injury Research collects and disseminates sports injury data on permanent disability and death from catastrophic brain and spinal cord injuries. The National Electronic Injury Surveillance System gathers data on emergency room visits from 100 hospitals.3 These three systems provide data restricted either by region or by case severity and may exclude individuals with concussion who did not receive medical attention or were not referred to emergency rooms. Other studies focus on relationships between concussion cases and population characteristics, and aid in concussion prevention by identifying at-risk populations. Prior analyses on how and to whom concussions occur in a given sport are essential in prevention programs.2 For example, age, gender, position of play, mechanisms of concussion, and the interactions of these factors have been studied and provide important information that can inform prevention programs. There is not yet enough evidence to suggest age or level of competition affects the risk of concussion.6 However, age plays a role in concussion recovery. High school students demonstrate prolonged memory dysfunction after sports-related concussion when compared with college athletes.7 Gender is another factor that has frequently been studied. Among those with a history of two or more concussions, female athletes performed significantly better than male athletes on verbal memory, visual memory, motor processing speed, and reaction time at baseline tests.8 However, another study of soccer players found that female soccer players performed worse on neurocognitive testing and reported more symptoms postconcussion than did male soccer players.9 Thus, the effect of gender on concussion risk is mixed. Nevertheless, Dick’s review of literature found that

women’s somatic symptoms after traumatic brain injury (TBI) were worse than men’s.10 In addition, types of sport and athleterelated factors are predictive factors of sports concussion. For male athletes, American football and Australian rugby players are at higher concussion risk. For female athletes, concussion risk is greater for soccer or basketball participants.6 Some sport positions, such as linebackers, offensive linemen, and defensive backs, are at greater risk compared with others, such as receivers. Further, body mass index greater than 27 kg/m2, body checking in ice hockey, and training time less than 3 hours per week all increase the risk of concussion.6

Future of Epidemiology in Concussion Prevention Developing effective sport-related concussion prevention programs depends upon increasing our knowledge of concussion rates, patterns, and risk factors.11 The results of epidemiology in concussion can suggest unusual problems and the need for specific intervention. Thus, it is necessary to obtain precise descriptive data on the incidence of concussion and enhance the accuracy of data. Some possible strategies may include mandatory reporting of incidents to ensure complete counts of well-defined cases. Current injury surveillance data still depend on voluntary reports and thus a more comprehensive involvement is needed. In addition, the existing systems lack injury surveillance data for adults who take part in recreational and professional sports.

EDUCATION IN CONCUSSION PREVENTION Goals The goal of education in concussion prevention is to ensure that accurate information on concussion is communicated to stakeholders.12 However, increasing knowledge about concussion would not be the ultimate purpose of concussion education. Eventually, by effectively providing adequate education, all stakeholders would develop an awareness of concussion risk

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and athletes’ safety and alter their behaviors accordingly.1

Approach People take an educational approach to achieve a change when they believe that individuals will do the right things if they understand why they need to do, what is being advocated, and how to carry it out.1 This approach underlines the importance of knowledge generation and dissemination. Provvidenza et al propose that knowledge creation involves three steps: (1) knowledge inquiry, (2) knowledge synthesis, and (3) knowledge tools/products.12 The three steps are applied to sports concussion education and discussed below. First, we need to investigate current knowledge about concussion. Subjects covered in education may include concussion prevention, impact of concussion, signs and symptoms of concussion, and proper concussion management. In addition, information should reflect evidence from research. Content may be generated from scientific research studies, concussion laws in the United States, or rules enforced by national sport organizations to reduce concussion and injury risk.12 Second, research studies should be translated and synthesized into practical applications for different stakeholders, including coaches, athletes, athletic trainers, parents, health care providers, physicians, student athletes, and the public. Knowledge needs to be tailored to the specific needs of users because stakeholders benefit from specific, individualized knowledge.12 Learning outcomes are optimized by considering the needs of the target audience. For example, medical personnel may need education on the identification of concussions, assessment, testing options, treatment, and guidelines on returning to play. Coaches and athletes may need information on proper fit and use of equipment, player respect, sport rules, and symptom reporting.12 Moreover, athletes need proper training on sports-specific techniques like tackling, body checking, and hitting the ball with the head before they apply these skills in game situations.13 Third, learning outcomes are also enhanced by the way information is disseminated.

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In addition to traditional face-to-face education and printed materials, multimedia and the Internet can play an important role in concussion education. For example, organizations develop Web sites that enhance concussion awareness (e.g., the “Heads Up” project created by Centers for Disease Control and Prevention). Peer support groups on Facebook (e.g., Twin Tiers Sports Post-Concussion Support Group) or Twitter help people relate personal experience with brain injuries. It is suggested that these discussion groups be moderated by health care professionals or concussion-based organizations, so proper and accurate concussion advice may be given effectively.12 Moreover, social media can serve as a vehicle for communicating sport science research and concussion information (e.g., Sports Concussions. org on Facebook). In addition to the educational approach, the social influence approach works toward influencing social norms to convince individuals that they must act in the prescribed way.1 The social influence approach confirms the importance of concussion-related groups in concussion education and prevention. For instance, nurses and physicians influence patients by providing concussion information in their medical offices. Sport leagues can pressure athletes to act in a way that is acceptable. Healthy and concussed athletes, parents, coaches, athletic trainers, helmet manufacturers, and physical education teachers can educate those around them about concussion.12 These people may possess a unique social influence on a certain group of people and make a great impact by sharing knowledge. Moreover, media play an important role in the social influence approach. Media can educate the public and athletes by addressing the long-term consequences of concussion on the quality of life among retired athletes. For example, television networks including ESPN, PBS, CNN, and other major media have reported the suicide of National Football League (NFL) star athletes and their suffering from chronic traumatic encephalopathy, a condition thought to be triggered by repetitive head trauma or multiple concussions. Such reports could enhance public understanding of concussion and concussion management as well as

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encourage athletes not to sacrifice their health for victory.

Outcomes and Future It is suggested that more injuries result less from the lack of knowledge than from failure to apply what is known.1 For example, in 2007, Centers for Disease Control and Prevention (CDC) started a project called “Heads Up: Concussion in High School Sports,” intended to enhance coaches’ knowledge of concussion. After reviewing the “Heads Up” materials, 46.6% of youth coaches strongly agreed that it was their job to educate their athletes about concussions; but although 76% indicated that concussion was a very serious problem in youth sports, 23.2% still did not believe it was a serious problem. Moreover, 13% of respondents disagreed that their role as a coach included educating athletes about sports-related concussions.14 On the one hand, this result showed that the CDC was effective in addressing the concussion prevention and management to coaches. On the other hand, it also revealed that the educational materials may not be enough in changing the attitude toward concussion among coaches. Thus, there are barriers to knowledge use for stakeholders.12 Besides the educational approach, the persuasion and behavioral modification approaches have not been studied or implemented as much in concussion education. The persuasion approach is based on the idea that people act only if they are sufficiently motivated. The behavioral modification approach is based on the idea that people learn techniques for action when they find the outcomes rewarding.1 More evidence and effective incentives are needed to persuade stakeholders that they need to change their behaviors. Possible rewarding outcomes include reducing the likelihood of concussion, fewer training hours lost, and prolonging their time on the field. In addition, the education and enforcement of fair-play rules can serve the function of behavior modification. By trying to win points without excessive penalties, players would gradually engage in less risky behaviors. Finally, although concussion education can improve knowledge about concussion, it is not known if receiving concussion education will

reduce the incidence of concussions2; nor do we find that knowledge enhancement and educational strategies effectively result in less risky behaviors and better safety perceptions. Future studies are needed to identify the relationship between education and various outcome measures. Nevertheless, even if the education outcomes have not been proved to be consistently helpful in preventing sports concussion, educational efforts still remain a valuable component in understanding this injury.15

ENVIRONMENTAL MODIFICATION IN CONCUSSION PREVENTION Definition and Goals When it is too difficult to change attitudes and behaviors, modifying the environment is a way to provide automatic or passive protections that make behavioral change easier or even unnecessary.1 While playing sports, especially contact sports, hits and collisions are unavoidable. However, modifications in the physical environment (such as surroundings and protective product designs) and sociocultural environment (such as sport culture and play rules) may lessen the impact of collisions and eventually reduce the risk of concussion.

Approach In the physical environment, designing appropriate equipment (e.g., helmets, dental guards) and safer physical surroundings are ways to prevent concussions. Navarro did a literature review seeking evidence that protective equipment prevents concussion.16 However, there was a lack of conclusive data. No protective equipment was shown to produce a zero-risk incidence of sports-related concussion. For example, customized mandibular orthotics in football players, mouth guards in rugby players, headgear use in soccer players, and face shields in ice hockey and field hockey players all provided poor evidence of decreasing the risk of concussion. Helmets are designed to protect against major brain injuries, but to date there is no concussion-proof helmet.2,16 The inherent material design of the football helmet can prevent high-energy impact forces associated

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with catastrophic head injuries but cannot prevent the lower-impact forces that are typically associated with concussions.16 In addition, safer physical surroundings, such as sized rinks (that have larger dimensions) and breakaway goal posts in ice hockey, have been shown to reduce players’ collisions and injuries.2 Several factors concerning sociocultural environment are important in the prevention of sports concussion. For example, game rules and behaviors could foster intense hits and thus increase concussion risks. The study found that the odds ratio of an emergency visit because of the concussion increased significantly after allowing bodychecking among minor league hockey players.17 In ice hockey games, penalties related to rough play and injury occurred four times more frequently during games with regular rules than those with fair-play rules.18 In addition, players in leagues without the FairPlay Program (FPP) shoved and hit more compared with games with FPP.19 The rules of the game set expectations for conduct on the playing field and define infractions for players. Thus, consistent modeling of clean play by coaches and officials can create a better sociocultural environment to prevent concussions.13 Another factor that may promote the incidence of concussion is the culture that values aggression.20 Preventing the incidence and severity of sports concussion will require a shift in attitude and expectation on the part of players, coaches, officials, administrators, parents, and fans.13 Media are one of the creators of the sociocultural environment in sports. The enthusiasm of reports on aggression and the portrayal of concussion incidents as acceptable occupational risks could pressure athletes to neglect their own safety.20

Outcomes and Future Studies of environmental modifications in physical designs and sociocultural milieu have demonstrated inconclusive results that did not apply to all sports in all scenarios. For example, another aspect that deserves attention is the use of protective equipment as a weapon.2 Helmets used in football or elbow and shoulder pads designed to reduce injury to joints are often used as offensive weapons

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to inflict head injuries. Future investigations on the product design and regulations should consider the effects of using protective equipment as attacking tools. There is also a possibility that the use of protective equipment may cause players to engage in more risky behaviors and thus contribute to an increase in a concussion risk.13 Moreover, the influence of media in shaping the sociocultural environment cannot be neglected. After an analysis of newspapers articles reporting brain injury in ice hockey from Canada and America, Cusimano et al found that newspapers depicted violence and aggression that led to TBI both as integral and unavoidable risks associated with playing the game.20 Although these articles also condemned violence in ice hockey and recognized the significance of TBI, it was not clear that readers and fans would interpret violence as unnecessary or negative after reading these articles. There seems to be ambivalence toward aggression and violence in the media reports of ice hockey games. On the one hand, the reports underline the consequence of TBI and devalue the role of violence. On the other hand, the media still to some extent tolerate the incidents of TBI, perhaps because the excitement of the games is usually accompanied by aggression and injuries. In the future, it would be worthwhile to examine the relationship between media reports of concussion incidents and public awareness of concussion management.

ENFORCEMENT IN CONCUSSION PREVENTION Definition and Goals Government has to exercise its authority to intervene when public health is a concern, and sports concussion is one of these concerns. Statutory language can either require or prohibit people’s behavior, usage of products, or environmental places.1 Legislation, compared with other forms of regulation, is usually not voluntary in nature. Hence, legislation standards can be effective means of concussion prevention, especially during the preinjury and injury phase.1

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Examples Every state in the United States now has a concussion law, most of which target youth and sports-related concussions. Although the exact stipulations of these laws vary among states, the overall theme is to increase recognition of concussion in young athletes and ensure that they are appropriately cleared for return to play after concussion.21 Sports concussion law is designed to reduce youth sports concussion and raise awareness of TBI. The acts typically apply to school-sponsored sports in grades 7 through 12. Under the legislation, an athlete who reports or shows symptoms or signs of a concussion must be removed from practice or game for at least 1 day and would not be allowed to return to practice or competition until cleared by a health provider. This legislation standardizes the roles and responsibilities of athletes, parents or guardians, coaches, and health care providers in this injury.13 As a consequence, when any youth player on the field has experienced a hit or other possible incident of concussion, failure to immediately attend to the injury of a player is not only a medical problem but also a legal concern. The legislation also mandates educational outreach to coaches, parents, and athletes. Adler and Herring argue that educational outreach alone is not enough to improve youth sports concussion care.15 It is the sports concussion laws that enact change. Combining those educational efforts with legislative ones is more effective. Another example of enforcement regarding sports concussion is the lawsuit between the NFL and retired NFL players. In 2013, more than 4800 retired players sued the NFL for its negligence of athletes’ safety that caused their head injuries. A proposed 765 million dollars of settlement between NFL and thousands of former players was made. According to this settlement, league retired players who have been diagnosed with Lou Gehrig disease (damages to motor neurons in the brain and spinal cord) would be eligible for awards as high as $5 million. Four million dollars would be awarded for a death involving TBI. Players suffering from dementia would be eligible for payments of $3 million.22 This lawsuit has attracted much

attention, and the final resolution of this settlement is still pending. The NFL makes the bulk of its income from media rights and advertisement, and it is suspected that the relatively small compensation that was proposed would not pressure the league to emphasize professional athletes’ safety. Unless the NFL is found to be liable for the negligence of head injuries and is required to pay an enormous price for such negligence, this lawsuit may not encourage the league to invest in medical research, equipment improvement, rules modification, better concussion management enforcement, or other measures to ensure athletes’ health and safety. On the other hand, the estimated amount of the settlement and the federal judge’s concern of its insufficiency confirm that the medical expenses of long-term care for head injuries and related sequelae among these retired athletes is significant, not to mention their diminished life quality. Comparing the substantial medical cost and the priceless quality of life for professional athletes, investments in concussion prevention and provision of better concussion management are more cost-efficient. Instead of paying millions of dollars to cope with the consequences of concussion, it is more useful and meaningful to spent efforts on preventing its occurrence. The philosophy in injury prevention is to reduce the likelihood of long-term morbidity by proactively addressing causative factors beforehand,23 and it appears that the NFL’s focus on compensation rather than prevention is counter to this philosophy.

Outcomes and Future Washington State was the first to pass a concussion safety law for youth sports players. Several research studies have been conducted in Washington State to evaluate the effect of this concussion legislation. In 2010, 1 year after the passage of a concussion law in Washington State, the data from surveys indicated that 85% of respondents were aware of this law, but only 73% of respondents knew that players must receive written clearance to return to play.24 It seemed that gaps in knowledge and practice still existed. In 2013, another study was conducted to

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examine the effectiveness of the same concussion law. These investigators found that high school football and soccer coaches were receiving substantial concussion education and had good concussion understanding. However, concussion education for athletes and parents was more limited.25 These results indicate that there is still room for improvement in the implementation of concussion laws even 3 years after the passage of concussion laws. Although the last state to pass a concussion law did so in January 2014, more studies are required to assess the effects of legislation. Studies of the effectiveness of these legislative efforts may be designed to measure posteducation knowledge retention testing (such as the previous findings in Washington State), and to survey school administrators and officials regarding policy implementation, change in concussion injury reporting rates, or decrease in disabling consequences of concussion.15

EVALUATION IN CONCUSSION PREVENTION Goals The goal of an evaluation in concussion prevention is to assess the effectiveness of prevention programs and identify the morbidity of concussion as an outcome measure. The results of an evaluation can be utilized to fulfill demands for accountability, prioritize resource allocations, enable efficient replication, and guide future program development.1

Approach Evaluation is an integral part of concussion prevention. The previous four Es addressed in this article—epidemiology, education, environmental modification, and enforcement—are highly correlated with the last segment, evaluation. For example, once concussion knowledge has been generated and disseminated, we need to evaluate the effectiveness of educational strategies and information on the target stakeholders. Also, all types of environmental modification, such as safety equipment or rule change, require evaluation of their impact on

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reducing risks and altering behaviors. Moreover, an evaluation of the influence of concussion legislation provides important reference and accountability information to legislators for setting future statuary standards.1 Finally, there is a need for accurate epidemiological studies on data collection and an injury registry to identify the changes in morbidity pre- and postconcussion interventions. The evaluation of a program’s impact depends on epidemiological data. Van Tiggelen and his colleagues proposed efficacy, efficiency, and compliance in the method of sports injury prevention.23 These concepts can be applied to the evaluation of sports concussion prevention. For example, the scientific efficacy of the intervention should be considered in the evaluation process. Moreover, to ensure the efficiency of implementation, the interventions should demonstrate that potential impact on the enhancement of athletes’ wellbeing outweighs the input of financial, practical, and administrative efforts. Finally, even if the efficacy and efficiency of a program are confirmed, successful outcomes still depend on athletes’ compliance of the program guidelines.23 Therefore, the evaluation should also determine if there is good compliance and controlled risk-taking behavior of the individual athlete.

Outcomes and Future The implementation of evaluation in this model of concussion prevention provides the recursive loop through which the efficacy of each of the previously described dimensions is assessed and analyzed. The evaluation of intervention strategies, as well as the effectiveness of education, environmental modifications, and enforcement policies, will inform epidemiological constructs, increasing the body of knowledge in the field and impacting future prevention activities.

CONCLUSION The classic epidemiological triad of host, agent, and environment has been combined with a modification of Tator’s five Es to present a model of prevention of sports-

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related concussion that is a loop, rather than a linear practice.2 The five Es addressed in this article can be conceptualized as a recursive process. Effective and accurate evaluation will facilitate the implementation of environmental modification, enforcement, and education. In addition, education, enforcement, and environmental modification manifest their influences on sports concussion prevention independently and collaboratively. Education effects are made more powerful with the enforcement of legislation. Environmental modification needs to be implemented through education efforts and statuary control (enforcement). Stakeholders need to be educated on current rules or legislation and the usage of new safety designs. Finally, the effects of these efforts will exhibit on the epidemiological studies, and these data will inform evaluation studies of further program development on environmental modification, education, and enforcement.

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21. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus 2012;33 (6):E11, 1–9 22. Breslow JM. Public Broadcasting Service. Judge rejects $765 million NFL concussion settlement. Available at: http://www.pbs.org/wgbh/pages/ frontline/sports/league-of-denial/judge-rejects-765million-nfl-concussion-settlement/ Updated January 14, 2014. Accessed April 29, 2014 23. Van Tiggelen D, Wickes S, Stevens V, Roosen P, Witvrouw E. Effective prevention of sports injuries: a model integrating efficacy, efficiency, com-

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pliance and risk-taking behaviour. Br J Sports Med 2008;42(8):648–652 24. Shenouda C, Hendrickson P, Davenport K, Barber J, Bell KR. The effects of concussion legislation one year later—what have we learned: a descriptive pilot survey of youth soccer player associates. PM R 2012;4(6):427–435 25. Chrisman SP, Schiff MA, Chung SK, Herring SA, Rivara FP. Implementation of concussion legislation and extent of concussion education for athletes, parents, and coaches in Washington State. Am J Sports Med 2014;42(5):1190– 1196

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A model of prevention of sports concussion in adults.

This article discusses the definitions of prevention and presents a model that addresses multidimensional aspects of sports concussion prevention from...
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