Authors: Luis Gude, MD, Gillian Hotz, PHD
Gillian Hotz Ph.D
Lois Pope LIFE Center – 1-40, (R-48)
1095 NW 14th Terrace, Miami, Florida 33136
Gillian A. Hotz, PhD is a research professor at the University of Miami, Miller School of
Medicine and a nationally recognized behavioral neuroscientist and expert in pediatric and adult neurotrauma, concussion management, and neurorehabilitation. Dr. Hotz is the director of the KiDZ Neuroscience Center, WalkSafe, BikeSafe, and SkateSafe programs, and has been co-director of the Miller School of Medicine’s Concussion Program since 1995. She continues to assess and treat many athletes from Miami-Dade County public and private high schools, the University of Miami, and from other colleges and the community.
Concussions in Cheerleaders Reported from a Countywide Concussion Injury Surveillance System
The purpose of this study was to advocate for the acceptance of cheerleading as a sport so that its athletes are eligible for the same resources available to other sports, such as concussion education programs and injury surveillance systems. The subjects of this study were cheerleaders from Miami Dade County public high schools who sustained a sports related concussion (SRC) from August 2015 to June 2019, identified from the Miami Concussion Model Concussion Injury Surveillance System. The database is compiled from reports submitted by certified athletic trainers after a suspected concussion, from post-injury ImPACT tests, and from patients who present to the University of Miami Sports Concussion Clinic for evaluation. A total of 29 cheerleaders were identified. The 2018-19 academic year accounted for 45% of reported concussions, representing a large increase in number compared to previous years. This was observed after increased emphasis was placed on certified athletic trainers to report SRC in cheerleaders. On average cheerleaders with SRC were withheld from sport for 26.2 days, and 38% had prolonged recovery of >28 days. Cheerleaders perform complex athletic maneuvers that put them at risk of injury, particularly SRC. If considered a sport, cheerleading would be afforded the same benefits as other sports, including resources for better facilities, mandatory concussion education, ATC availability, baseline neurocognitive testing, and inclusion in injury surveillance systems. Increased knowledge of the long-term sequelae of concussions and repetitive head injuries has led to the development of concussion education programs and injury surveillance systems to protect athletes from these types of injuries. Although competitive cheerleading has been recognized as a sport, cheerleading as a whole has not, putting its athletes at risk as its participants are not included in these safety programs.
Key words: Concussions, Cheerleading, Player Safety, Education
Cheerleading has its origins in the late 1800s. Originally an all-male activity that consisted of leading cheers in support of their team, cheerleading has undergone many changes to become the team based athletic activity as it is currently known. Now dominated by female athletes, cheerleading includes acrobatic maneuvers such as stunts meant to entertain and encourage spectators to cheer for their team, or to compete as a sport in areas where it is recognized (9). It is estimated that 3.8 million children ages 6 and older participated in cheerleading in 2016 in the United States, increased from 3.2 million in 2007 (1). Children as young as 3 years old may join squads that are often associated with youth football teams. Cheerleading has also spread globally, and was given provisional recognition as a sport by the International Olympic Committee in 2016 with 116 national federations as members (11).
With the increase in participation and complexity of modern cheerleading activities, there has also been an increase in the number and rate of cheerleading injuries. Using the National Electronic Injury Surveillance System, Naiyer et al. (16) estimated that the number of cheerleading injuries increased by 242% from 1990 to 2012, and that from 2001 to 2012 the rate of concussion or closed head injury increased by 290% in children aged 5 to 18 years. Lincoln et al. (12) reported similar findings, with a 26% mean annual increase in the number of concussions in cheerleaders in a public high school system from 1997 to 2008. Despite having a low rate per athletic exposure compared to other sports, sports related concussions (SRC) are a common injury in cheerleading, accounting for 4-30% of all cheerleading injuries (7, 12, 18, 21).
The topic of whether or not cheerleading is a sport has been a subject of debate. A study of collegiate cheerleaders showed that its participants have fitness levels equivalent to those participating in other sports such as basketball and tennis (17). Despite the recognition that great skill and athleticism is required to participate in cheerleading, some still do not consider cheerleading a sport as there is no direct competition. This has led to the development of teams that focus on competition, such as competitive spirit or STUNT, which has complicated the discussion as cheerleaders in non-competitive squads may still be performing the same maneuvers as those in competitive teams but without the same safety measures in place. In 2012, the American Association of Pediatrics (AAP) called for the recognition of cheerleading as a sport given the athleticism required to participate in and the risk of injury associated with modern cheerleading (6).
In response to the growing national awareness of SRC in athletes, a comprehensive concussion management team formed at the University of Miami in 2012. In collaboration with the Miami-Dade County (MDC) Public School Athletics Department, this team developed the Countywide Concussion Program (CCP) with the goals of reducing the incidence and improving the management of SRC. The CCP focuses on training and education to increase awareness and identification of SRC, and includes a Concussion Injury Surveillance System (CISS). Since 2012, the CCP has been implemented in all 35 MDC Public High Schools and is mandatory for contact sports (10). Each high school is required to have a certified athletic trainer (ATC) on staff to manage the CCP at that school.
The Greater Miami Athletic Conference (GMAC), which oversees public high school athletic activities in MDC, has not recognized cheerleading as a sport and therefore it is not mandated that cheerleaders are included in the CCP. However, the ATC of each high school are encouraged to consider cheerleading a sport at yearly concussion education and training workshops, and to include its athletes in the CCP. The purpose of this study was to report on SRC sustained by cheerleaders in MDC public high schools captured by the CISS, and to advocate for the acceptance of cheerleading as a sport so that its athletes may benefit from the same resources that other sports receive and inclusion in concussion management protocols.
The subjects of this study were cheerleaders from the 35 MDC public high schools who sustained a SRC from August 2015 to June 2019 and were identified from the CISS database. The database is compiled from ImPACT test results and two REDCap databases. ImPACT is a computer-based neurocognitive assessment used in baseline testing and then again when an athlete is suspected of having sustained a SRC. Under the CCP all athletes participating in contact sports are required to perform a baseline ImPACT test, and it is recommended that any athlete suspected of having a SRC undergo post-injury testing. REDCap is a web-based application used to capture data for clinical research and to create databases. The first REDCap system is generated from reports submitted by the ATC of each of the MDC public high schools. This 33 data point report is submitted once an athlete who has sustained a SRC has been cleared by a physician or is otherwise lost to follow-up. The second REDCap database is generated by the University of Miami Sports Concussion Clinic research staff who input information of patients who present to the concussion clinic for evaluation. The CCP and CISS are described in detail by Hotz et al. (10). Subjects who attended high school in a different county or private or charter schools were excluded from this study. Approval for this study was obtained from the Miami-Dade County Public School Department of Athletics and University of Miami Institutional Review Board.
A total of 29 cheerleaders with SRC were identified, 28 females and 1 male. The average age was 16 years, with juniors (46%) and seniors (29%) sustaining the most SRC. There was a large increase in the number of reported SRC in the 2018-19 academic year in comparison to previous years. Demographic information is reported in Table 1.Table 1: Demographics Data
|Age (mean, years)||16|
|Academic Year of Injury|
|*Other includes unknown race or ethnicity, non-hispanics with unknown race, non-hispanic Asians, & Haitians|
Most of the SRC were sustained at practice (28), except for 1 at a school performance. From the data reported, 10 cheerleaders were either bases or spotters and 7 were flyers. Of the 29 subjects identified, 21 (72%) were cleared for return-to-play with an average time withheld from sport of 26 days, 8 (38%) of which had a prolonged recovery of >28 days. Eight (28%) subjects were lost to follow-up (See Table 2).Table 2: Description of Sample
|History of Concussion|
|Base or Spotter||10||59%|
|Time out of play (days)*|
|Mean (SD)||26.2 (15.7)|
|Median (25th%, 75th%)||22 (14, 36)|
|Minimum, maximum||7, 59|
|* Measured by days from date of concussion until date cleared by clinician.
Our findings show that cheerleaders in their junior and senior year sustained the majority of SRC in this population, which may be due to these upperclassmen having more experience in the sport and therefore participate in complex maneuvers that put them at higher risk of injury. Prior to the start of 2018-19 academic year, CCP staff placed increased emphasis on the importance of reporting SRC in cheerleaders to ATC during their yearly training workshop. Subsequently there was a large increase in the reported number of injuries compared to previous years, accounting for 45% of reported SRC in this study. Our findings are similar to those of other studies that have shown that the highest number of injuries to cheerleaders occur at practice (7, 16, 18, 22), and that bases and spotters sustain more SRC than flyers (20).
It is estimated that between 1 and 1.9 million SRC occur per year in US children aged less than 18 years, and that the majority of these patients are not seen in health care settings (4). Identifying a SRC when it occurs is crucial, not only so that it may be managed properly, but also to reduce the risk associated with repetitive head injuries. Individuals with SRC experience a wide variety of physical, cognitive, and emotional symptoms that can decrease quality of life and interfere with normal daily activities (8, 24). Academic accommodations, such as curriculum and environmental adjustments, are typically recommended to help the student return to pre-concussion performance levels (14). In this report, 67% of cheerleaders received academic accommodations.
Most adolescents with SRC typically recover within 2 weeks post injury (3, 8, 13, 26). Reports of the percent of children with concussion who develop persistent post-concussive symptoms lasting over 28 days has varied greatly, from 1.5% in high school athletes (15) to 31% of children presenting to pediatric emergency departments within the Pediatric Emergency Research Canada network (25). Those with prolonged recovery of over 30 days are at increased risk of long-term sequelae such as anxiety, and mood and behavior disorders (3). Compared to males, female patients with concussion report higher symptom burden, take longer to return to baseline, and are more likely to have symptoms persist for over 30 days (5, 19, 25, 26). In a review of the National High School Sports-Related Injury Surveillance Study, Currie et al. (7) noted that cheerleading accounted for the second highest proportion of injuries that led to a time loss of over 3 weeks or medical disqualification from sport. In addition, cheerleading accounts for 65% of catastrophic sports related injuries in females (2). In our report, cheerleaders were withheld from sport for an average of 26 days, and 38% of cheerleaders who were cleared for return to play had a prolonged recovery of over 28 days. These findings suggest that the injuries, including concussions, that cheerleaders sustain may be more severe when compared to other sports (7).
The major limitations of this study stem from the methods by which SRC in cheerleaders are reported in MDC. Through the CCP, ATCs are responsible for the data input of SRC in multiple sports. Since cheerleading is not considered a sport by GMAC, monitoring under the CISS is not mandatory and the ATC relies on the coaches or athlete to report an event. These injuries are underreported to the ATC as they may not be present at practices or other events, and it is not mandated that the athlete obtains return-to-play clearance. This likely contributed to the high number (8, 28%) of cheerleaders lost to follow-up in this report. The CISS does not capture athletes with SRC who presented to facilities outside of the University of Miami Sports Concussion clinic, such as pediatricians, emergency departments, or urgent health centers, unless the ATC submitted the surveillance report. Accurate reporting of SRC in cheerleading would help bolster the argument on the importance of making cheerleading a sport. It could also identify athletic programs with high numbers of SRC and target them for improvement.
Currently the CISS contains entries specific for cheerleading, however these are often left unanswered by the ATCs leading to incomplete data sets. The data collected through the CISS could be improved by providing information on cheerleading positions and routines to ATC during their yearly protocol training sessions, and by adding sections that detail the mechanism of injury, including the maneuver being performed, fall height, and type of surface (23). This information could help identify high-risk activities and guide future rule changes to protect cheerleaders.
Cheerleaders perform complex athletic maneuvers that put them at risk of injury, particularly SRC. Our findings support the stance of the AAP on the importance of recognizing cheerleading as a sport. If considered a sport, cheerleading would be afforded the same benefits as other sports, including resources for better facilities, mandatory concussion education, ATC availability, baseline neurocognitive testing, and inclusion in injury surveillance systems. Future studies should monitor and track SRC and other injuries in cheerleading to improve safety and to advance regulations and policies in this sport. Additional research is required to compare the sporting activities and injuries of cheerleaders in competitive and non-competitive squads.
APPLICATIONS IN SPORT
Increased knowledge of the long-term sequelae of concussions and repetitive head injuries has led to the development of concussion education programs and injury surveillance systems to protect athletes from these types of injuries. Although competitive cheerleading has been recognized as a sport, cheerleading as a whole has not, putting its athletes at risk as its participants are not included in these safety programs.
The authors would like to thank the UHealth Sports Medicine Institute, the Miami-Dade County School Board Athletics Department, and all the Miami-Dade County Certified Athletic Trainers. We would also like to thank the Goldstein Family for their continued support of the Countywide Concussion Program.
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