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Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years --- United States, 2001--2009

Traumatic brain injuries (TBIs) from participation in sports and recreation activities have received increased public awareness, with many states and the federal government considering or implementing laws directing the response to suspected brain injury (1,2). Whereas public health programs promote the many benefits of sports and recreation activities, those benefits are tempered by the risk for injury. During 2001--2005, an estimated 207,830 emergency department (ED) visits for concussions and other TBIs related to sports and recreation activities were reported annually, with 65% of TBIs occurring among children aged 5--18 years (3). Compared with adults, younger persons are at increased risk for TBIs with increased severity and prolonged recovery (4). To assess and characterize TBIs from sports and recreation activities among children and adolescents, CDC analyzed data from the National Electronic Injury Surveillance System--All Injury Program (NEISS-AIP) for the period 2001--2009. This report summarizes the results of that analysis, which indicated that an estimated 173,285 persons aged ≤19 years were treated in EDs annually for nonfatal TBIs related to sports and recreation activities. From 2001 to 2009, the number of annual TBI-related ED visits increased significantly, from 153,375 to 248,418, with the highest rates among males aged 10--19 years. By increasing awareness of TBI risks from sports and recreation, employing proper technique and protective equipment, and quickly responding to injuries, the incidence, severity, and long-term negative health effects of TBIs among children and adolescents can be reduced.

NEISS-AIP is operated by the U.S. Consumer Product Safety Commission and contains data on initial visits for all injuries in patients treated in U.S. hospital EDs. NEISS-AIP data are drawn from a nationally representative subsample of 66 of 100 NEISS hospitals that are selected as a stratified probability sample of hospitals in the United States and its territories that have a minimum of six beds and a 24-hour ED (5). NEISS-AIP provides data on approximately 500,000 injury-related cases each year.

For this analysis, sports and recreation--related injuries included those injuries among children and adolescents aged ≤19 years that occurred during organized and unorganized sports and recreation activities (e.g., bicycling, skating, or playground activities). Each case was initially classified into one of 39 mutually exclusive sports and recreation--related groups on the basis of an algorithm using both the consumer products involved (e.g., bicycles, swing sets, or in-line skating equipment) and the narrative description of the incident obtained from the medical record. For the analysis, 30 of the categories were examined separately and the remaining nine were combined into the "other specified" category. Persons with sports and recreation--related injuries were classified as having a TBI if the primary body part injured was the head and the principal diagnosis was either concussion or internal organ injury. Sports and recreation--related cases were excluded if the injury was violence-related (e.g., intentional self-harm, assault, or legal intervention). Additionally, data regarding persons who were dead on arrival or who died in the ED were excluded.

Each case of sports and recreation--related injury was assigned a sample weight based on the inverse probability of selection; these weights were added to provide national estimates of sports and recreation--related injuries. National estimates were based on weighted data for 453,655 ED visits for all sports and recreation--related injuries (of which 36,230 were TBIs) during 2001--2009. Confidence intervals were calculated using a direct variance estimation procedure that accounted for the sample weights and complex sample design (5). Significance of trends over time was assessed using weighted least squares regression analysis.

During 2001--2009, an estimated 2,651,581 children aged ≤19 years were treated annually for sports and recreation--related injuries. Approximately 6.5%, or 173,285 of these injuries, were TBIs (Table 1). Approximately 71.0% of all sports and recreation--related TBI ED visits were among males; 70.5% were among persons aged 10--19 years. An estimated 2.5% of children and adolescents with sports and recreation--related injuries were hospitalized or transferred to other facilities, compared with an estimated 6.6% of those with sports and recreation--related TBIs. From 2001 to 2009, the estimated number of sports and recreation--related TBI visits to EDs increased 62%, from 153,375 to 248,418, and the estimated rate of TBI visits increased 57%, from 190 per 100,000 population to 298. During this same period, the estimated number of ED visits for TBIs that resulted in hospitalization ranged from 9,300 to 14,000 annually but did not show a significant trend over time.

Overall, the activities associated with the greatest estimated number of TBI-related ED visits were bicycling, football, playground activities, basketball, and soccer (Table 2). Activities for which TBI accounted for >10% of the injury ED visits for that activity included horseback riding (15.3%), ice skating (11.4%), golfing (11.0%), all-terrain vehicle riding (10.6%), and tobogganing/sledding (10.2%).

Activities associated with the greatest estimated number of sports and recreation--related TBI ED visits varied by age group and sex (Table 3). For males and females aged ≤9 years, TBIs most commonly occurred during playground activities or when bicycling. For persons aged 10--19 years, males sustained TBIs most often while playing football or bicycling, whereas females sustained TBIs most often while playing soccer or basketball, or while bicycling.

Reported by

Julie Gilchrist, MD, Div of Unintentional Injury Prevention, Karen E. Thomas, MPH, Likang Xu, MD, Lisa C. McGuire, PhD, Victor Coronado, MD, Div of Injury Response, National Center for Injury Prevention and Control, CDC. Corresponding contributor: Julie Gilchrist, jgilchrist1@cdc.gov, 770-488-1178.

Editorial Note

The findings in this report indicate that, from 2001 to 2009, the number of sports and recreation--related ED visits for TBI among persons aged ≤19 years increased 62% and the rate of TBI visits increased 57%. These increases might reflect an increased participation in sports and recreation, an increased incidence of TBI among participants, and/or an increased awareness of the importance of early diagnosis of TBI. Because the number of ED visits for TBIs that resulted in hospitalization did not trend upward significantly, increased awareness likely contributed to the increasing number of ED visits for TBI. Additionally, this report highlights that the rates of sports and recreation--related TBI visits were higher among persons aged 10--19 years than among younger persons. This finding might be associated with age-related increases in participation in higher-risk activities (e.g., competitive contact sports) or increases in participants' weight and speed, leading to greater momentum and force of impact (6).

Risk for TBI is inherent to physical activity and can occur during any activity at any age. To minimize TBI in sports and recreation activities, primary and secondary prevention strategies should be implemented. Primary prevention strategies include: 1) using protective equipment (e.g., a bicycle helmet) that is appropriate for the activity or position, fits correctly, is well maintained, and is used consistently and correctly; 2) coaching appropriate sport-specific skills with an emphasis on safe practices and proper technique; 3) adhering to rules of play with good sportsmanship and strict officiating; and 4) attention to strength and conditioning (7). Secondary prevention strategies include increasing awareness of the signs and symptoms of TBI and recognizing and responding quickly and appropriately to suspected TBI.

Participants suspected of having a TBI should be removed from play, never returned to play the same day, and allowed to return only after evaluation and clearance by a health-care provider who is experienced in diagnosing and managing TBI (4). Return to play is a critical decision because children and adolescents are at increased risk for both repeat concussion during sports and recreation--related activities and for long-term sequelae, delayed recovery, and cumulative consequences of multiple TBIs (e.g., increased severity of future TBIs and increased risk for depression and dementia) (8,9).

To promote the prevention of, recognition of, and appropriate responses to TBI, CDC has developed the Heads Up initiative, a program that provides concussion and mild TBI education to specific audiences such as health-care providers, coaches, athletic trainers, school nurses, teachers, counselors, parents, and student athletes. The newest addition to this initiative is Heads Up to Clinicians: Addressing Concussion in Sports Among Kids and Teens, an online course for health-care professionals that was developed with support from the CDC Foundation and the National Football League.* This course, which offers free continuing education credits, addresses the appropriate diagnosis, management, and referral of TBI, and education about TBI that is critical for helping young athletes with concussion achieve optimal recovery and reduce or avoid significant sequelae.

The findings in this report are subject to at least five limitations. First, injury rates for specific activities could not be calculated because of a lack of national participation and exposure data. Therefore, the estimates cannot be used to calculate the relative risks for TBI associated with any particular sport or activity. Second, NEISS-AIP only includes injuries recorded by hospital EDs and excludes persons who sought care in other settings or who did not seek care. Therefore, this report underestimates the actual burden of TBI from sports and recreation among children and adolescents. Third, NEISS-AIP includes only the principal diagnosis and primary body part injured and therefore cannot capture TBIs that were secondary diagnoses. For example, skull fractures, which commonly involve TBI, are listed as fractures of the head, and not as TBIs, resulting in underestimation of the number of sports and recreation--related TBI ED visits. Fourth, NEISS-AIP narrative descriptions do not provide detailed information about injury circumstances (e.g., whether the activity was organized, whether the injury occurred during training or competition, or whether protective equipment was used), so NEISS-AIP cannot be used to assess the impact of these factors. Finally, the available data do not allow for assessment of whether the increased number of ED visits from 2001 to 2009 resulted from an increase in incidence or an increase in awareness of TBI and concussion, or from shifts in location of medical care, or other reasons.

The frequency of TBIs and the wide variety of activities associated with them underscore the need to prevent, recognize, and respond to sports and recreation--related TBIs. Additional information and resources regarding TBI and the Heads Up initiative, including tool kits and on-line trainings, are available at http://www.cdc.gov/concussion.

References

Schatz P, Moser RS. Current issues in pediatric sports concussion. Clin Neuropsychol 2011;25:1042--57. Zhao L, Han W, Steiner C. Sports related concussions, 2008. Statistical brief no. 114. Rockville, MD: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project; 2011. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb114.jsp. Accessed October 5, 2011. CDC. Nonfatal traumatic brain injuries from sports and recreation activities---United States, 2001--2005. MMWR 2007;56:733--7. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport---the 3rd International Conference on Concussion in Sport, held in Zurich, November 2008. J Clin Neurosci 2009;16:755--63. Schroeder T, Ault K, eds. The NEISS sample (design and implementation): 1997 to present. Bethesda, MD: US Consumer Product Safety Commission; 2001. Available at http://www.cpsc.gov/neiss/2001d011-6b6.pdf. Accessed October 4, 2011. Proctor MR, Cantu RC. Head and neck injuries in young athletes. Clin Sports Med 2000;19:693--715. CDC. Concussion in sports: what can I do to prevent concussions? Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/concussion/sports/prevention.html. Accessed October 3, 2011. Buzzini SR, Guskiewicz KM. Sport-related concussion in the young athlete. Curr Opin Pediatr 2006;18:376--82. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury. J Head Trauma Rehabil 2006;21:375--8.

What is already known on this topic? Risk for traumatic brain injury (TBI) is inherent to participation in sports and recreation activities; compared with adults, children and adolescents have an increased risk for TBIs with increased severity and prolonged recovery. What is added by this report? From 2001 to 2009, the estimated number of sports and recreation--related TBI visits to emergancy departments (EDs) increased from 153,375 to 248,418, and the estimated rate of TBI visits increased from 190 per 100,000 population to 298. The two most common sports and recreation activities associated with ED treatment for TBI were bicycling and playing football. What are the implications for public health practice? To minimize TBI in sports and recreation activities, prevention strategies should be implemented, including practicing skills, strength and conditioning, and sportsmanship, and using protective equipment (e.g., bicycle helmets). Secondary strategies include knowing the signs and symptoms of TBI, responding to suspected TBI appropriately, and permitting return to activity only after evaluation and clearance by an experienced health-care provider.

TABLE 1. Estimated annual number and rate* of emergency department visits for all nonfatal injuries and nonfatal traumatic brain injuries (TBIs) related to sports and recreation activities among persons aged ≤19 years, by selected characteristics --- National Electronic Injury Surveillance System--All Injury Program, United States, 2001--2009 Characteristic TBIs All visits for sports and recreation--related injuries % of all visits for injuries that were TBIs No.† Rate 95% CI No.† Rate 95% CI Age group (yrs) ≤4 14,406 71 (48--93) 158,876 778 (642--914) 9.1 5--9 36,756 184 (136--231) 529,481 2,646 (2,232--3,060) 6.9 10--14 60,272 291 (226--357) 1,084,041 5,242 (4,391--6,092) 5.6 15--19 61,851 294 (226--361) 879,184 4,177 (3,561--4,793) 7.0 Sex Male 122,970 292 (225--360) 1,810,260 4,302 (3,664--4,940) 6.8 Female 50,310 126 (96--155) 840,838 2,098 (1,757--2,439) 6.0 Disposition Treated and released 159,010 194 (148--239) 2,569,161 3,127 (2,645--3,610) 6.2 Hospitalized/Transferred 11,477 14 (9--19) 67,277 82 (66--98) 17.1 Observed 1,954 2 (1--4) 4,946 6 (4--9) 39.5 Other/Unknown§ 844 1 (0.6--1.5) 10,196 12 (9--16) 8.3 Year 2001 153,375 190 (137--242) 2,784,375 3,440 (3,057--3,823) 5.5 2002 143,744 177 (134--220) 2,669,721 3,287 (2,756--3,818) 5.4 2003 152,882 188 (138--237) 2,647,990 3,250 (2,673--3,826) 5.8 2004 148,651 182 (133--230) 2,619,490 3,202 (2,623--3,780) 5.7 2005 162,371 198 (148--248) 2,592,682 3,159 (2,621--3,697) 6.3 2006 172,463 209 (158--261) 2,659,199 3,228 (2,672--3,783) 6.5 2007 184,424 223 (168--277) 2,637,890 3,184 (2,621--3,746) 7.0 2008 193,235 232 (180--284) 2,615,004 3,143 (2,611--3,675) 7.4 2009 248,418 298 (216--379) 2,637,881 3,162 (2,590--3,734) 9.4 Total 173,285 211 (162--260) 2,651,581 3,228 (2,737--3,719) 6.5

TABLE 2. Estimated annual number of emergency department visits for all nonfatal injuries and nonfatal traumatic brain injuries (TBIs) related to sports and recreation activities among persons aged ≤19 years, by type of activity --- National Electronic Injury Surveillance System--All Injury Program, United States, 2001--2009 Activity TBIs All visits for sports and recreation--related injuries % of all visits for injuries that were TBIs No.* 95% CI (±) No.* 95% CI (±) Bicycling 26,212 (6,809) 323,571 (48,566) 8.1 Football 25,376 (4,845) 351,562 (47,448) 7.2 Playground 16,706 (5,198) 210,979 (37,050) 7.9 Basketball 13,987 (3,077) 375,601 (47,607) 3.7 Soccer 10,436 (3,736) 135,988 (39,167) 7.7 Baseball 9,634 (2,401) 121,309 (22,175) 7.9 All-terrain vehicle riding 6,337 (3,481) 59,533 (14,061) 10.6 Skateboarding 6,004 (2,455) 101,577 (31,907) 5.9 Swimming 4,557 (1,699) 62,745 (14,500) 7.3 Hockey† 4,427 (2,749) 45,450 (24,405) 9.7 Miscellaneous ball games§ 4,065 (1,477) 66,543 (15,306) 6.1 Horseback riding 3,638 (1,266) 23,842 (5,169) 15.3 Moped/Dirt bike riding¶ 3,370 (978) 39,363 (9,209) 8.6 Scooter riding 3,336 (779) 54,561 (11,784) 6.1 Gymnastics** 3,319 (948) 71,248 (13,881) 4.7 Combative sports†† 2,981 (786) 50,639 (10,941) 5.9 Softball 2,735 (756) 49,345 (10,002) 5.5 Exercising 2,406 (825) 77,069 (11,731) 3.1 Tobogganing/Sledding 2,377 (948) 23,306 (8,383) 10.2 Trampolining 2,323 (823) 86,584 (17,540) 2.7 Golf§§ 1,887 (609) 17,078 (3,510) 11.0 Ice skating 1,673 (631) 14,608 (4,241) 11.4 Volleyball 1,396 (483) 34,513 (7,568) 4.0 Amusement attractions¶¶ 1,266 (470) 15,781 (3,844) 8.0 Roller skating/Unspecified skating 1,126 (316) 34,717 (8,280) 3.2 Go-cart riding 875 (308) 11,078 (2,280) 7.9 In-line skating 853 (335) 25,350 (7,515) 3.4 Track and field 449 (171) 15,553 (3,003) 2.9 Racquet sports*** 323 (125) 9,306 (1,984) 3.5 Bowling 153 (74) 6,574 (1,524) 2.3 Other specified††† 9,059 (4,630) 136,210 (44,511) 6.7 Total 173,285 (40,284) 2,651,581 (403,378) 6.5