Incidence of Head Injury Among Synchronized Skaters: Rates, Risks, and Behaviors

Western Michigan University
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Dissertations Graduate College

8-2018

Incidence of Head Injury Among Synchronized
Skaters: Rates, Risks, and Behaviors
Gretchen L. Mohney
Western Michigan University, gretchen.mohney@wayne.edu

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INCIDENCE OF HEAD INJURY AMONG SYNCHRONIZED SKATERS:
 RATES, RISKS, AND BEHAVIORS

 by

 Gretchen L. Mohney

 A dissertation submitted to the Graduate College
 in partial fulfillment of the requirements
 for the degree of Doctor of Philosophy
 Interdisciplinary Health Sciences
 Western Michigan University
 August 2018

Doctoral Committee:

 Linda Shuster, Ph.D.
 Robert Baker, M.D., Ph.D.
 Shelly Fetchen DiCesaro, Ph.D., LAT

© 2018 Gretchen L. Mohney

INCIDENCE OF HEAD INJURY AMONG SYNCHRONIZED SKATERS:
 RATES, RISKS, AND BEHAVIORS

 Gretchen L. Mohney, Ph.D.

 Western Michigan University, 2018

 Data regarding risk and rates for head injury and concussion specific to the sport of

synchronized skating is absent from literature. This study investigated the rate and risk for head

injury and concussion as a function of team level, identified behaviors to include education,

neurocognitive baseline screening and protective equipment utilization, and the implementation

of return to sport protocols.

 An anonymous cross-sectional survey was implemented at the 2018 U.S. Synchronized

Skating Championships. Participants were female members of a qualifying team, ages 13 and

older, at the intermediate participation level and higher. The survey response rate was 42%

(520/1232). Among the survey respondents, 7% (36/520) reported head injury in the practice

setting and 1% (4/520) in the competitive setting. Among respondents who reported head injury

(n=37), 68% (25/37) reported a team skill injury, with senior level reporting the highest 22%

(13/75) rate. Among the sample population (n=520), the odds of sustaining a head injury during

a team skill was 2.13 times more likely than during individual skill (OR: 2.13, CI: 1.06, 4.30;

p=.03). The odds of sustaining a head injury during practice was 9.59 times higher than in

competition (OR:9.59, CI: 3.30, 27.15; p

A chi-square analysis did not reveal a significant association between education and

return to skating without medical intervention X 2 (1, n = 520) = .391, p =.532. Baseline

neurocognitive screening was reported at 25% (128/520) among the survey respondents. Only

.06% (3/520) of the survey respondents reported utilizing protective headgear. Among those

reporting concussion (n=26), 92% reported receiving a return to sport/learn progression.

Emphasis on concussion education and medical provider access should be targeted to team skill

development in the practice setting.

ACKNOWLEDGEMENTS

 I would like to begin by acknowledging the Interdisciplinary Health Science Ph.D.

faculty Dr. Nickola Nelson, Dr. Kieran Fogarty, Dr. Amy Curtis, Dr. Mary Lagerwey and Dr.

Linda Shuster for the opportunity to expand out of my comfort zone. A special and specific

thank you to both Dr. Nickola Nelson and Dr. Linda Shuster for their advising, revising and

support throughout the years of transition and progression.

 Secondly, I’d like to thank Dr. Robert Baker and Dr. Shelly Fetchen-DiCesaro for their

support, time, enthusiasm, and expert counsel. You are both invaluable and I am so fortunate you

share in my passion.

 Most importantly, I would like to thank my children Gabe, Garrett, and Alexis Mohney

for being my “study buddies” throughout their high school years and their patience regarding the

laptop that always seemed to divert my focus. My dear husband, Ken Mohney, thank you for

standing by me through the storm. You’ve always seen more in me than I’ve ever seen in myself.

Thank you for your encouragement when I needed it most.

 Lastly, I’d like to thank Leslie Graham from U.S. Figure Skating for her continued

support. To the many athletes (skaters) I have had the privilege to serve and or treat over the

years, thank you for the inspiration.

 Gretchen L. Mohney

 ii

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ............................................................................................................ ii

LIST OF TABLES ......................................................................................................................... vi

CHAPTER

I. INTRODUCTION ......................................................................................................................1

 Research Questions ..............................................................................................................2

 Hypothesis............................................................................................................................3

 Definitions of Synchronized Skating Levels .......................................................................4

II. LITERATURE REVIEW ............................................................................................................5

 Concussion ...........................................................................................................................5

 Concussion Screening ..........................................................................................................8

 Return to Sport ...................................................................................................................10

 Policy .................................................................................................................................13

 Concussion Education........................................................................................................14

 Concussion Prevention.......................................................................................................15

 Injury Surveillance .............................................................................................................16

 Risk and Rates....................................................................................................................18

 Risk Classification .............................................................................................................19

 Figure Skating and Head Injury .........................................................................................19

 Synchronized Skating and Head Injury .............................................................................20

 iii

Table of Contents—Continued

CHAPTER

III. METHODS ..............................................................................................................................23

 Subject Recruitment ...........................................................................................................23

 Instrumentation ..................................................................................................................23

 Informed Consent Process .................................................................................................25

 Risks, Costs, and Protection of Human Subjects ...............................................................25

 Location and Confidentiality of Data Collected ................................................................26

 Analysis..............................................................................................................................27

IV. RESULTS ................................................................................................................................28

 Descriptive Statistics of Study Population.........................................................................28

 Practice Statistics ...............................................................................................................28

 Competition Statistics ........................................................................................................31

 Concussion Education Statistics ........................................................................................33

 Baseline Concussion Testing Statistics..............................................................................33

 Headgear ............................................................................................................................35

 Head Injury ........................................................................................................................36

 Practice...................................................................................................................36

 Type of Injury ........................................................................................................37

 Type of Skill ..........................................................................................................37

 Injury Risk .............................................................................................................38

 Competition........................................................................................................................39

 Type of Injury ........................................................................................................39
 iv

Table of Contents—Continued

CHAPTER

 Type of Skill ..........................................................................................................40

 Head Contact......................................................................................................................41

 Return from Concussion ....................................................................................................43

V. DISCUSSION ...........................................................................................................................45

 Limitations .........................................................................................................................52

 Future Recommendations ..................................................................................................52

REFERENCES ..............................................................................................................................54

APPENDICES

 A. Participant Recruitment Email ......................................................................................63

 B. Consent and Paper Survey.............................................................................................64

 C. U.S. Figure Skating Permission ....................................................................................66

 D. WMU HSIRB Approval................................................................................................67

 E. WSU IRB Approval ......................................................................................................68

 v

LIST OF TABLES

1. Graduated return-to-sport protocol ............................................................................................11

2. Projected survey sample ............................................................................................................26

3. Survey response rates per synchronized skating level ...............................................................28

4. Survey respondents reported state of residence .........................................................................29

5. Reported team practices per week by respondents per skating level .........................................30

6. Reported hours per week at team practice per skating level ......................................................30

7. Reported hours per week at individual practice per skating level .............................................31

8. Reported competition behavior during the past training year ....................................................32

9. Reported sports competed in by survey population reporting other sports per
 skating level ...............................................................................................................................32

10. Reported concussion education by survey population per skating level .................................33

11. Site of concussion education among those reporting concussion education ...........................34

12. Reported baseline concussion screening by survey population per skating level ...................34

13. Reported baseline screening type by survey population reporting baseline
 screening ..................................................................................................................................35

14. Reported administrative personnel/site for baseline screening per skating level ....................36

15. Reported head injury during practice per synchronized skating level .....................................37

16. Reported type of injury among total injuries reported per synchronized skating
 level ..........................................................................................................................................38

17. Reported skill per head injury during practice per synchronized skating level .......................39

18. Logistic regression for head injury among skating level and practice exposure in
 the practice setting ...................................................................................................................40

 vi

List of Tables—Continued

19. Reported head injury during competition per synchronized skating level ..............................40

20. Reported type of injury among total injuries reported per synchronized skating
 level ..........................................................................................................................................41

21. Reported hitting head and returned to skating without seeking medical advice
 per skating level .......................................................................................................................41

22. Number of head hits without seeking medical advice for return to skating per
 skating level .............................................................................................................................42

23. Reported rationale for returning to skate without medical per skating level ...........................42

24. Type of medical advice received among concussed respondents ............................................44

 vii

CHAPTER I

 INTRODUCTION

 Synchronized skating is the newest discipline within the sport of figure skating involving

16-20 skaters on a team, representing the largest competitive discipline within United States

Figure Skating (USFS), the national governing body for the sport of figure skating. Synchronized

skating competitive programs do not consist of elements such as high impact multi-rotational

jumps typical in other disciplines of figure skating but exhibit the increased potential for

collision and contact injury attributable to the team elements of this sport. Previous investigation

has revealed the majority of head injuries in synchronized skating are related to team elements

such as lifts, blocks and intersections. However, head injury and concussion incidence data,

specific to the synchronized skating population, is absent from peer reviewed literature despite

the initial passing of concussion state law in 2009 and subsequent implementation by all 50

states in 2014. There is a need for research into head injury and concussion, so that

synchronized skating can develop evidence-based educational materials for stakeholders (e.g.,

parents, athletes, coaches and healthcare providers). Without this research evidence, the industry

may rely on anecdotal report to develop these materials. With the extensive advancements in

recognition, treatment, and policy implementation regarding concussion in sport during the past

decade, it is appropriate that head injury incidence and concussion are investigated in

synchronized skating to employ the best evidence-based practice prevention and intervention

techniques.

 This study aims to:

 1. Identify and differentiate athlete-based rate and risk for concussion and head injury

 among synchronized skaters.

 1

2. Identify and differentiate team level-based rate and risk for head injury and concussion

 among synchronized skaters.

 3. Identify current preventative behaviors to include baseline neurocognitive screening

 and protective equipment utilization

 4. To investigate the implementation of return to skate protocols after concussive injury.

Research Questions

 1. What is the individual skill-based risk for head injury and concussion among

 synchronized skaters?

 2. What are the individual skill rates for head injury and concussion among

 synchronized skaters?

 3. What is the team level risk for head injury and concussion among synchronized

 skaters?

 4. What are the team level rates for head injury and concussion among synchronized

 skaters?

 5. How do head injury and concussion rates vary among synchronized skating team

 levels?

 6. Do head injuries occur more frequently during team practice or individual element

 practice?

 7. Do head injuries occur more frequently during competition or practice?

 8. If the synchronized skating athlete sustained a concussion did they:

 a. Receive a return to skate protocol?

 b. Receive a return to learn protocol?

 2

9. Do synchronized skaters wear protective equipment to prevent head and concussion

 injury?

 a. If so, what is it?

 b. What is their rationale for wearing it?

 10. Do synchronized skaters receive concussion education?

Hypothesis

 1. Team-skill risk and rates of head injury will be higher than individual skill-based risk

 and rates due to increased risk of collision and contact injury.

 2. As level of synchronized skating increases, so do risk and rates for head injury and

 concussion contributable to advanced skill requirements.

 3. Head injury and concussion occurs more frequently at practice than at competition.

 4. Athletes who participate in other sports in addition to synchronized skating have a

 higher rate of baseline neurocognitive screening.

 5. Athletes who sustain concussion receive return to skate and return to learn protocols

 more frequently when they participate in other sports in addition to the sport of

 synchronized skating.

 6. Synchronized skaters do not wear protective equipment to prevent head injury and/or

 concussion.

 7. Synchronized skaters who do wear protective equipment have sustained previous

 concussive injury and wear it for only practice.

 8. Synchronized skaters receive concussion education at their skating clubs and/or rinks

 due to the passing of state laws in all 50 states in the U.S.

 3

Definition of Synchronized Skating Levels (USFS, 2018)

 Intermediate: Skaters must be under the ae of 18 and have passed the juvenile moves in

 the field test.

 Novice: Skaters must be under 16, with the exception of four skaters who may be 16 or

 17 and have passed the intermediate moves in the field test.

 Junior: Skaters must be at least 15 years old and have passed the junior moves in the field

 test.

 Senior: Skaters must be at least 15 years old and have passed the junior moves in the field

 test.

 Collegiate: Skaters must be enrolled in a college or degree program as full-time students

 and have passed the juvenile moves in the field test.

 Adult: All skaters must be 21 years or older, with the exception that up to four skaters

 may be 18, 19 or 20. All skaters must have passed at least one of the following tests:

 preliminary moves in the field, adult bronze moves in the field, preliminary figure or

 preliminary dance.

 Masters: All skaters must be 25 years or older, with the majority of the team 30 years or

 older.

 4

CHAPTER II

 LITERATURE REVIEW
Concussion

 Concussion is a mainstream concern in sports medicine as the evolution in recognition,

treatment, and education has transpired across healthcare and sport during the past 10 years.

(Alla, S., Sullivan, J., McCrory, P. & Hale, L., 2011). Among people ages 15-24 years, sports are

rated second to motor vehicle accidents as the leading cause of traumatic brain injury, which has

become classified as a public health issue by the U.S. Centers for Disease Control and

Prevention (Bell, J., Breidling, M., & DePadilla, L., 2017). During the year 2009, the initial state

law addressing concussion recognition and management passed in the State of Washington,

which is most commonly referred to as the “Zackery Lystedt Law” (Simon & Mitchell, 2016).

This law was initiated after the athlete was returned to competitive play while symptomatic from

his initial head injury. Subsequently, he sustained a second collision force during the football

game, to incur permanent brain damage (Cook, A., King, H., & Polinkandroitis, J., 2014). The

risk of premature return-to-sport (RTS) following a concussion, as exemplified by the Lystedt

case, may result in short-term and long-term comorbidities, and/or predispose an individual to

second impact syndrome, resulting in permanent disability and/or death (McCrory et al., 2013;

Cook et al., 2014; Broglio et al., 2014). Evidence has emerged suggesting that contact, collision,

and combat sport athletes are at an increased risk for depression and cognitive deficits later in

life, and this risk appears to be related to a history of multiple head impact injuries; however,

there is a need for further investigation into the relationship between multiple injuries and long-

term brain health (Manley et al., 2017; McCrory et al., 2017).

 5

As research continues to evolve and the medical models of prevention, diagnosis, and

treatment advance, so does the definition of “Concussion”. The International Concussion in

Sport Group defined concussion as an alteration in mental status that may or may not involve

loss of consciousness and has been described as a complex pathophysiological process affecting

the brain, induced by biomechanical forces (McCrory et al., 2013). Further distinction has

evolved with the sport related concussion (SRC) classification, specifically identifying

concussion related to sport and defined as the immediate and transient symptoms of mild

traumatic brain injury specifically related to a force incurred during sport participation (McCrory

et al., 2013). There is a lack of clarity in the literature regarding the name for traumatic brain

injuries (TBI) that are less severe, with the terms mild TBI (mTBI) and concussion sometimes

being used interchangeably. However, the interchangeability of mild traumatic brain injury

(mTBI) and concussion continues to be debated due to lack of data and terminology confusion

(McCrory et al., 2017). The most recent definition of sports related concussion (SRC), as

determined by the Concussion in Sport Group (CISG) in 2016, is that SRC is a traumatic brain

injury induced by biomechanical forces (McCrory et al., 2017).

 The medical etiology of concussion emerges from both contact and inertial forces

(Meaney & Smith, 2011). Sports related concussion (SRC) commonly results in a rapid onset of

short-lived neurological function impairment that resolves spontaneously, however, signs and

symptoms may evolve over minutes to hours (McCrory et al., 2017). Clinical signs and

symptoms typically reflect a functional disturbance that may or may not involve loss of

consciousness (McCrory et al., 2017; Kutcher & Giza, 2014). During the acute phase of injury,

SRC evolves and is considered to be among the most complex injuries in sports medicine to

diagnose, assess and manage (McCrory et al., 2017). Focal impact commonly caused by blunt

 6

trauma and/or direct contact with a hard surface may result in skull fracture with accompaniment

of a mild to severe traumatic brain injury (TBI) (Meaney & Smith, 2011). Injury may occur both

at the site of impact and in regions distant from the site (Meaney & Smith, 2011). Research

continues to emerge identifying the acceleration, particularly rotational or angular acceleration,

experienced at the moment of impact by the brain as the primary cause of concussion (McIntosh,

Patton, Fréchède, Pierré, Ferry & Barthels, 2014; Meaney & Smith, 2011). Causative factors of

concussion may include an acceleration/deceleration force which may result from a blow to the

body and/or whiplash force at the neck (Kutcher & Giza, 2014). However, the brain may

experience the biomechanical influence of injury without physically coming into contact with

another object (Meaney & Smith, 2011; Kutcher & Giza, 2014; McCrory et al., 2017).

Interestingly, the head may be more vulnerable to temporal impacts derived from the lateral

aspect due to the angular acceleration of the head in the coronal plane in unhelmeted athletes

(McIntosh et al., 2014).

 Sports related concussion signs and symptoms typically evolve with rapid change during

the acute phase of injury, therefore sideline evaluations by licensed health care providers

becomes essential (McCrory et al, 2016; Kutcher & Giza, 2014; Broglio et al., 2014). The

challenges of concussion management reach beyond the acute clinical presentation to the

development of chronic conditions such as post-concussion syndrome, cognitive impairment,

depression and chronic traumatic encephalopathy (Kutcher & Giza, 2014; McCrory et al., 2017;

Broglio et al., 2014). Concussive diagnosis is often difficult due to the potential coexistence of

concussion-related and non-concussion-related pathology. These include migraine headache,

sleep disturbance, cervical spine pathology, anxiety and mood disorders and attention deficit

disorders (ADHD) (Kutcher & Giza, 2014; McCrory et al., 2017). Differential diagnosis may

 7

prove difficult, as the aforementioned non-concussive pathologies may exhibit similar signs and

symptoms of a concussion (McCrory et al., 2017; Kutcher & Giza, 2014). Loss of consciousness

is not required for a concussion diagnosis, while anterograde or retrograde amnesia is estimated

to occur in 30-50% of concussed patients, with headache reported as the most common symptom

(Kutcher & Giza, 2014).

Concussion Screening

 Sports related concussion is considered an evolving injury with rapidly changing signs

and symptoms during the acute state of injury (McCrory et al. 2017). The utilization of

neurocognitive screening/diagnostic tools may assist the medical practitioner during sideline

injury management and when determining return to sport progression, confirming the presence

of a concussion and providing assistance in the identification of early sports-related injury and/or

chronic neurobehavioral impairments (Giza et al., 2013; McCrory et al. 2017; Broglio et al.,

2014). Kutcher and Giza (2014) recommended that concussion management should involve

frequent serial evaluations. The utilization, type, and consequent implementation of

neurocognitive screenings, therefore, are under the discretion of the healthcare provider

rendering medical advice and/or treatment. Baseline neurocognitive screens are often employed

by ATs and as a part of their respective scope of practice (Broglio et al., 2014). Athletic Trainers

(AT) are typically present for concussion screening, diagnosis and return to sport among athletic

populations, as they are medical care providers specifically trained in the triage and management

of acute sports injury, to include concussion (Kutcher & Giza, 2014; Courson et. al, 2014). The

baseline neurocognitive screening tools may include balance tests such as the Balance Error

Scoring System (BESS) and the King-Devick Test of visual tracking, the Immediate Post-

Concussion Assessment and Cognitive Testing (ImPACT) assessment tool and electronic and

 8

paper pencil versions of the Standardized Assessment of Concussion (SAC) (Kutcher & Giza,

2014; Giza et al., 2013; Kriz, P., Mannix, R., Taylor, A., Ruggieri, D., & Meehan, W., 2017).

 Generally, neuropsychological screening tools may be administered by computer and/or

paper and pencil mechanism and commonly assess memory performance, reaction time and

speed of cognitive processing as do the variety of aforementioned specific screening tool types

(Giza et al., 2013). Although neurocognitive screening tools should be administered by licensed

health care providers both on the sideline and/or in the clinical setting, team personnel (coaches

and staff) should immediately remove an athlete from activity if suspecting a head

injury/concussion in order to minimize the risk of further injury (Giza et al., 2013). The team

personnel should restrict athlete return to sport until the athlete has been evaluated by a licensed

healthcare provider with training in the diagnosis and management of concussion (Giza et. al.,

2013; Manley et al., 2017; McAllister & McCrea, 2017; McCrory et al., 2017). Such guidelines

for recognition and removal are imperative, as the evolution of the clinical syndrome resultant

from the biomechanical force evolves over time and may not fully present itself until further

cognitive and physical exertion is experienced (Kutcher & Giza, 2014; McAllister & McCrea,

2017).

 The most commonly utilized sideline neuropsychological tool among sports medicine

providers reported by the CISG is the Sport Concussion Assessment Tool (SCAT), initially

created by the Concussion in Sport Group in 2004. The purpose of its development was to assist

medical providers in standard objective assessment of concussion and to provide education to the

public (Echemendia et al., 2017). As empirical evidence evolved, revisions to the tool have

occurred to include versions for medical practitioners, such as MDs and ATs (SCAT 2), the

pocket SCAT for non-medical personnel, the Child SCAT3 for children under the ages of 13,

 9

and modifications of scoring concurrent with evidence regarding the reliability and validity of

previous versions (Echemendia et al., 2017). The most recent revision has resulted in the SCAT5

tool for medical personnel and the Concussion Recognition Tool (CRT) for non-medical

personnel, which replaced the Pocket SCAT2 reinforcing the importance recognition and

removal of athletes from play when suspecting possible sports related concussion (Echemendia

et al., 2017). Systematic review has concluded the SCAT5 has relatively low bias and is a useful

screening and evaluative tool, however, there are limited data on the use of the tool in athletes

with disabilities or with those from non-Western cultures and from language groups other than

English. In addition, the utility of the tool is limited for tracking recovery and making return to

sport decisions (Echemendia et al., 2017).

Return to Sport

 Research continues to emphasize the need to restrict athlete immersion into a contact-risk

activity post-concussion until the athlete is asymptomatic (Kutcher & Giza, 2014; Giza et al.,

2013). The most recent Concussion in Sport Consensus Statement (2017), continues to

emphasize the importance of a gradual return to sport (RTS) progression and a multidisciplinary

healthcare provider approach to ensure optimal patient outcomes and the avoidance of secondary

comorbidities with early and/or improper RTS (McCrory et al., 2017). Additionally, the CISG

indicated that adolescents should not return to sport until they have successfully returned to

school (McCrory et al., 2017). Optimally, the treatment protocol for concussion in sport

emphasizes a graduated 6 step return-to-sport process as established by the multidisciplinary

Concussion in Sport Group (CISG) (McCrory et al, 2017). During this stepwise progression

process, the athlete should only proceed to the next level if able to asymptomatically accomplish

each step of progression. Symptoms to monitor include somatic, cognitive, emotional

 10

fluctuation, loss of consciousness, and neurological deficits, balance impairments, behavioral

changes, cognitive impairments and sleep/wake disturbances. (McCrory et al., 2017; Broglio et

al., 2014) The athlete should be progressed every 24 hours to the next level, however, if

symptoms return and/or increase upon increased exertion, the athlete should return to the

previous level until able to complete the outlined exertional activity symptom free (McCrory et

al., 2017; Broglio et al., 2014) See Table 1.

Table 1. Graduated return-to-sport protocol.
Rehabilitation Stage Physical Activity
1 Daily activities that do not provoke symptoms
2 Walking or stationary cycling at slow to medium pace
3 Running or skating drills. No head impact activities
4 Harder training drills. May begin progressive resistance training
5 Following medical clearance, participate in normal training
6 Normal game play
Note: Retrieved from McCrory et al., 2017.

 Concussion symptoms include self-reported measures, in addition to observable

behaviors at time of injury, during recovery, and return to sport (Simon & Mitchell, 2016;

McCrory et al., 2013). During the RTS progression, self-report accuracy is imperative so that

stakeholders involved in athlete return to sport can employ proper restriction or progression

implementation (Mara, M., McIlvain, N., Fields, S., & Comstock R., 2012). Accuracy of athlete

self-report may be limited by athlete attitude and knowledge on concussion signs and symptoms

and importance of removal of play while in a vulnerable physiological state (Register-Mihalik et

al., 2013). Athlete compliance with graduated return to sport guidelines has been found to be

poor, with 1 in 6 returning prematurely (Mara et al., 2012). RTS decisions should be made using

objective criteria in the absence of influence from competitive emotion that may invoke a “play

 11

at all costs” mentality (Alla et al., 2011; McCrory et al., 2013). When coaches are left to oversee

a RTS progression, they may not be able to objectively remove an athlete from play (McCrory et

al., 2013; McNamee, Partridge, & Anderson, L., 2016). Coaches may be unable to identify and

evaluate further concussive symptoms due to a lack of proper education or may place their needs

and/or the needs of the team over those of the injured player (Lowrey & Morain, 2014;

McNamee et al., 2016; LaRoche, A., Nelson, A., Connelly, P., Walter, K., & McCrea, M., 2016).

 Studies have exposed athlete tendencies to underreport and/or fail to report concussion

symptoms to avoid being pulled from play, while the personal health risk may be immeasurable

(Register-Mihalik, J. et al., 2013; McNamee et al., 2016). This type of risky behavior may be

compounded by a coach whose job is dependent on the contest outcome, creating a conflict

between the best interest of the team relying on player participation and performance, and the

health consequences for the individual player. Inevitably, when a medical provider is not

available, the authority figure present for injury reporting and symptom differentiation is the

coach (Register-Mihalki, J., 2013). Several studies have illustrated that coaches have limited

knowledge and various misconceptions related to concussion (Mara et al., 2012; Esquivel et al.,

2013; Kroshus, E., Garnett, B., Hawrilenko, M. Baugh, C., & Calzo, J., 2015). There is a lack of

standard accredited education regarding concussion for coaches among various sporting

organizations and associations, and the required educational modes may also lack in creditability

(McNamee et al., 2016; Simon & Mitchell, 2016). Regardless of the ethical priority of the coach,

he/she may not be adequately equipped to detect false self-report when immersed in competitive

play emotion, which may be further complicated by variable self-report by the athlete navigating

internal and external pressures to participate (Kroshus et al., 2015). RTS decisions should be

made in an objective and unbiased fashion devoid of emotion (Courson et al., 2014; Ross, J.,

 12

Capozz, J., Matava, & Matava, J., 2012). “Doctor Shopping” has been reported by parents of

secondary school aged athletes, who visit numerous providers until they find one who will

provide clearance to RTS to ensure their child’s athletic participation, compounding the gravity

of responsibility that may be placed on a coach to determine readiness to play (Albano, A.,

Senter, C., Adler, R., Herring, S., & Asif, I., 2016; Lowery & Morain, 2014). Neurocognitive

deficits may exist despite the resolution of self-reported symptoms and emerge during the RTS

progression and physical exertion, further strengthening the most recent Concussion in Sport

Group recommendation (2017) for a multi-disciplinary healthcare team approach (McCrory et

al., 2017; Register-Mihalik, et al., 2013). The AT is commonly the only healthcare provider

present at games and practices, who is specifically trained in concussion recognition and

management among athletes who works in collaboration with, under the supervision of, or under

the direction of an MD/DO (Albano et al., 2016; Courson et al., 2014). The AT is in a

professional position to educate the variety of stakeholders, to include: athletes, parents, coaches,

athletic directors, and administrators on proper concussion management and implement

supervised RTS (Broglio et al., 2014). Register-Mihalik (2013) highlighted the need for multi-

factoral interventions which may include clinicians, parents, and coach education which

facilitates a positive concussion reporting environment. Currently, policy exists within all 50

states that if a concussion diagnosis is made, written RTS clearance is required by a healthcare

professional such as MD, DO, NP, PA, and ATs (Simon & Mitchell, 2016).

Policy

 As research has emerged highlighting both the potential short- and long-term effects of

traumatic brain injury, evidence-based recommendations continue to expand addressing

identification, prevention and treatment paradigms specific to sporting populations. Legislative

 13

actions enforcing education regarding concussion recognition, removal, and return to sport for

athletes, parents and sport personnel has concurrently developed (Simon & Mitchell, 2016).

Qualifications for healthcare providers managing concussion, and evidence-based medical

recommendations regarding sideline evaluation, removal and return to play consequently has

advanced (Alla et al., 2011; Courson et al., 2014; Simon & Mitchell, 2016)

 Currently, all 50 states in the United States have passed a form of state concussion

legislation, with the bulk of the statutes passing in 2011 (Simon & Mitchell, 2016, Gibson et al.,

2015). The laws were primarily developed to limit the cases of second impact syndrome

(Kutcher & Giza, 2014; Lowery & Moran, 2015). With the rapid increase of sports-related

concussion policies, however, an inconsistency in the implementation language has emerged

across the 50 states. Variations include compliance and education, enforcement of the athlete’s

removal from play, and the implementation of the recommended RTS process between sport

classifications and levels of play (Simon & Mitchell, 2016; McCrory et al., 2013, Broglio et al.,

2014). Compliance with the law or state association guidelines for concussion management and

RTS are typically complicated by problems with provider access, parent cooperation, and

education (Lowery & Moran, 2015).

Concussion Education

 The initial precursor to state-mandated concussion education was the implementation of

the Zackery Lystedt Law in 2009. The purpose of the law was to mandate that coaches, parents,

and youth participants are trained/educated about concussions and head injury prior to sports

participation and competition (Bonds, G., Edwards, W., Spradley, B., & Phillips, T., 2015).

Following in 2011, Natasha’s law went into effect in Texas. Natasha’s law was similar to the

Lystedt Law, however, it also required that coaches, licensed health professionals and physicians

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must complete training courses every two years (Bonds et al., 2015). As of April 2014, all 50

states and the District of Columbia have enacted concussion safety laws (Bonds et al., 2015).

The majority of concussion state laws throughout the country require concussion education

and/or distribution of education materials to stakeholders (coaches, athletes, parents of athletes)

the athlete’s removal from sport with suspected head injury, and evaluation by a health care

professional before returning to sport (Cook et al., 2014). Required education has primarily

focused on the signs and symptoms of concussion in order to employ proper recognition and

restriction of play and/ or referral for medical evaluation. The most common educational mode

has been in a dually signed information sheet by both the parent and athlete (Simon & Mitchell,

2016). However, the mechanism/mode of education is variable. As reported in a study by

LaRoche et al. (2016) in Wisconsin, only 60% of high school athletes surveyed were aware there

was a state law regarding concussions, although all athletes are required to sign the information

sheet regarding the law. Interestingly, these laws do not extend beyond school or state-based

organizations and are not overseen by state governing bodies. Recreational leagues and

independently sanctioned sports may not receive consistent information and regulation

enforcement (Cook et al., 2014; LaRoche et al., 2016; Bell et al., 2017; Bonds et al., 2015). As

reported in a recent study by Simon & Mitchell (2016), five states recommend coach education

but do not have specific requirements for instruction or proof of completion, 30 states mandate

yearly formal education, with the remaining 15 states ranging from one-time certification to

every 3 yrs.

Concussion Prevention

 The most recently published concussion consensus statement in sport has concluded that

the examination of the protective effect of helmets on sport related concussion is limited

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(McCrory et al., 2017). The strongest research to date supports the utilization of helmets for

skiing and snowboarding for injury protection and policy enforcing the reduction of checking in

youth hockey (Emery et al., 2017). Systematic review determined helmets contribute to the

prevention of focal injuries in sport, however the effectiveness in preventing concussion is less

clear (Emery et al., 2017).

 Helmet based measurement devices have begun to be explored, to include head-impact

exposure patterns for sport. However, the CISG determined that while the information gained on

head-impact exposure is useful, data are lacking regarding non-collision sports. (McCrory et al.,

2017). Investigation continues into the protective effect of mouthguards on concussion

incidence. Systematic reviews continue to find conflicting evidence, however, emerging

evidence investigating the sports of basketball, ice hockey, and rugby suggest there may be a

protective effect in collision and contact sports with the utilization of mouthguards (Emery et al.,

2017). Through meta-analysis, mouthguard utilization has been documented to decrease

orofacial injury across adult sports, such as ice hockey, rugby, basketball, and American football

(Emery et al., 2017).

Injury Surveillance

 Investigation into concussion has advanced with the utilization of sport injury

surveillance systems. These systems include the National High School Sports-Related Injury

Surveillance System (HS RIO), National Athletic Treatment Injury and Outcomes Network

(NATION), National Athletic Trainer Association (NATA) Injury Surveillance Program, NCAA

Injury Surveillance Program, MLB Health and Injury Tracking System (HITS), NHL Players

Association Concussion Program (NHLPA), and the NFL Injury Surveillance System (Kerr et

al., 2017). Although these systems investigate and report on different target populations in sport,

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data collectors for these surveillance systems are comprised of athletic trainers and sports

medicine practitioners who serve in a consistent employment capacity to these populations (Kerr

et al., 2007). The HS-RIO and NCAA-ISP are voluntary, web-based systems that rely on athletic

trainers for data collection capturing comprehensive information related to the TBI incident.

Examples include injury type, setting, position played and return to play (Bell et al., 2017).

These systems are limited to the school-sponsored sports and do not capture club, recreational, or

independently sanctioned sporting organizations, such as U.S. Figure Skating. (Bell et al., 2017).

Data collected from these surveillance studies serve to monitor injury trends, identify variables

that increase risk of injury, inspire the development of clinical intervention and prevention

strategies to minimize the short-term and long-term effects of injury, and validate informational

material for stakeholders to include parents, athletes, coaches, policy makers, and the sporting

industry (Kerr et al., 2017; Gessel et al., 2007). These systems, however, do not include the sport

of figure skating or the specific discipline of synchronized skating. Without surveillance data

specific to synchronized skating, evidence to support and/or guide prevention strategies remains

deficient. Sporting populations independently funded, such as synchronized skating, may indeed

have incidence risk and rates parallel to sports currently administering injury surveillance.

However, without investigation, rates and risks remain unknown.

 In a 2013 report, the National Academy of Science called for the CDC (Center for

Disease Control) to develop a comprehensive surveillance system for children in an effort to

enhance the tracking of head injury incidence and youth sports concussion outcomes among

youth ages 5 to 21 years of age (Bell et al., 2017). Specific variables of interest include

mechanism and sport of injury, level of competition (recreational or competitive), event type

(practice or competition), impact location, injury cause, and the signs and symptoms experienced

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(Bell et al., 2017). Most recently (2017), TBI incidence rates are derived from administrative

databases utilizing Clinical Modification (ICD-9-CM) codes to identify provider visits (Bell et

al., 2017). Although TBI may be identified utilizing this method, sports concussions are not able

to be identified or differentiated from other possible etiologies (Bell et al., 2017).

Risk and Rates

 According to research studies analyzing data from the National High School Sports

Related Injury Surveillance System, approximately 1.4 million injuries occur among athletes

participating in sports at the secondary school level with rates of concussion reported among

these athletes estimated at 300,000 per year (Courson et al., 2014). Injuries that occur in both

practice and game situations are accounted for, reporting increased risk and rates among sports

classified as contact and collision (Courson et al., 2014). The highest risk for concussion in sport

is among those participating in collision sport. Specifically cited include ice hockey, youth

rugby, and American football with rates ranging from .5 to 4.2 concussions per 1000 athlete

exposures (Emery et al., 2017). In a study by Gessel et al. (2007) investigating 9 high school

sports during the 2005-2006 school year, concussions were reported as 8.9% (396/4431) of the

total type of injuries reported. The practice setting was reported at 34.6% (137/396) and the

competition setting was reported to be 65.4% (259/396). The overall rate of concussion was .23

concussions per 1000 athlete exposures (A-E) (Gessel et al., 2007).

 In a recent study investigating sport and recreation related concussion in US youth, 1.1 to

1.9 million sports and recreation-related concussions were estimated to occur annually among

children ≤18 years of age (Bryan, M., Rowhani-Rahbar, A., Comstock, D., & Rivara, F., 2016).

However, practice and competition exposure measures, such as hours of practice and/or

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competition, were not accounted for due to difficulty of quantification for activity and variability

among the ages and levels (Bryan et al., 2016).

Risk Classification

 In 1994, the American Academy of Pediatrics published an analysis of medical

conditions affecting sports participation with corresponding classification of sports by contact

(American Academy of Pediatrics, 2001). Sports were categorized by the probability for contact

or collision. Examples of contact/collision sports were tackle football, rugby, soccer, and hockey.

Limited contact sports consisted of baseball, gymnastics, skiing and ice-skating. Non-contact

examples include dancing, golf, and track (AAP, 2001).

Figure Skating and Head Injury

 During a video analysis of falls experienced by pediatric ice skaters, it was determined

that skaters attempt to break their falls with their arms and hands and primarily fall in the

anterior direction (Knox & Comstock, 2006). The fall often results in a head and face injury due

to the slippery ice surface and the inability to brace (Knox & Comstock, 2006). Interestingly, the

authors suggested investigating the potential intervention of a glove with grip to increase the

ability of the hands and arm to minimize head/and face contact upon falling, however, further

differentiation on skating skill level was not provided (Knox & Comstock, 2006). It would be

interesting to see if this varied between recreational and competitive skating skill and should be

interpreted with caution.

 Alternate investigations into injury within the general sport of figure skating, consistently

report the on-ice practice setting as the primary site for head injury occurrence (Lipitz & Kruse,

2000; Porter, 2013). During a research investigation into injury among junior level skaters,

exclusive of the synchronized skating discipline, head injury was reported at (13.5%) among the
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pairs-specific discipline in figure skating (Dubravcic-Simunjak,S., Pecina, M., Kuipers, H.,

Moran, J., Haspl, M., 2003). Further data were given for female pair skaters reporting head

injury at 3.5% and male pair skaters reporting 7.7% (Dubravcic-Simunjak et al., 2003).

However, information on the types of head injuries sustained, e,g, concussion, was not provided.

 Most recently, figure skating injury incidence was investigated through a self-report

survey reported in a study by King et al. (2017). Concussion was reported by 2.1% of non-

qualifying competitors, 7.6% of qualifying competitions and 11.7 % of national/international

level competitors (King, D., DiCesaro, S., & Getzin, A., 2017). However, retrospective recall

was throughout the entire skating career limiting generalization due to recall bias and did not

delineate the discipline of synchronized skating.

Synchronized Skating and Head Injury

 Synchronized skating is the newest discipline within the sport of figure skating, involving

16-20 skaters on a team, representing the largest competitive discipline within U.S. Figure

Skating, the national governing body for sport figure skating (Abbott & Hecht, 2012). Teams

compete at a variety of levels, such as Juvenile, Intermediate, Novice, Junior, Senior, Collegiate,

Adult and Masters and skaters may qualify at one of three sectional competitions for the annual

U.S. Synchronized Skating Championships (United States Figure Skating Association, 2018).

The first and second place Senior level teams from the U.S. Synchronized Skating

Championships qualify to compete in the ISU (International Skating Union) World

Championships (Abbott & Hecht, 2012; USFSA, 2018). Since the initial U.S. Championship in

1984, and the initial ISU World Championship in 2000, the sport of synchronized skating has

continued to increase in popularity (Abbott & Hecht, 2012; Dubravcici-Simunjak, S., Kuipers,

H., Moran, J., Simunjak, B., & Pecina, M., 2006). During 2012-2013, approximately 9,000

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synchronized skating athletes competed in the United States on 579 different teams during the

competitive season, and these numbers continue to grow (Abbott & Hecht, 2012; USFS, 2018).

The most recent publicly available data from U.S. Figure Skating indicates that a 31% increase

in registered intercollegiate teams occurred from 2011-2015 (U.S. Figure Skating, 2016).

 Traditionally, synchronized skating competitive programs do not consist of elements such

as high impact multi-rotational jumps typical in other disciplines of figure skating, but exhibit

the increased potential for collision and contact injury attributable to the team elements of this

sport (Dubravcici-Simunjak et al., 2006). Synchronized skaters are commonly connected to

skaters next to them through a variety of upper extremity hold and release techniques, while

completing intricate skating skills within a very close proximity of one another at varying levels

of speed (Dubravcici-Simunjak et al., 2006; U.S. Figure Skating, 2016). At the elite senior level,

pairs lifts and single creative elements, more commonly seen among singles and pairs

disciplines, are integrated into the competitive program with specific judged criteria elements

unique to the sport of synchronized skating (Dubravcici-Simunjak et al., 2006; U.S. Figure

Skating, 2016; Abbott, & Hecht, 2012). Although this sport captures a broad base of participants

and continues to grow in popularity, investigation into sport-related injury remains minimal.

Advancements in technical difficulty, to include difficulty in lifts, alterations in speed, and

intricate step sequences may increase risks for trauma. These technical advancements may be

emphasized as the sport of synchronized skating continues to grow in participation rates in its

quest for official designation as a Winter Olympic Games Sport (USFSA, 2018; Abbott & Hecht,

2013).

 There is one published study to date identified by the primary investigator in the peer

reviewed literature investigating injuries specific to synchronized skating (Dubravcic-Simunjak

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et al., 2006). This study collected information from senior level competitors during the 2004

World Synchronized Skating Championship in Zagreb, Croatia. This study described all injuries

sustained since the athlete began skating, decreasing the strength of its finding due to the due to

the demands on the participants’ long-term memory. The single level skating skill population

surveyed (senior level only) limits generalizability to the rest of the synchronized skating

population, which varies in age group and skill level (Dubravcic-Simunjak et al., 2006; Soligard

et al., 2014). This study did identify injury to the head among 19.8% of the survey respondents,

with injury occurrence attributable to team elements (lifts, blocks, and intersections) during on-

ice practices (Dubravcic-Simunjak et al., 2006). However, no further differentiation was noted

for practice or competition setting, nor was the type of head injury recorded.

 The aforementioned studies occurred prior to the rapid advancements in concussion

recognition and treatment paradigms, which began in 2009. With the extensive advancements in

recognition, treatment, and policy implementation regarding head injury and concussion for sport

during the past decade, it is appropriate that injury incidence and concussion are investigated in

synchronized skating to employ best evidence-based practice interventions (Simon & Mitchell,

2016; Courson et al., 2014; Patel, D., Fidrocki, D., & Parachuri, V., 2017).

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