Authors: Gillian Hotz¹, Jacob R. Griffin², Hengyi Ke³, Raymond Crittenden IV⁴, Abraham Chileuitt⁵

Corresponding Author:

Gillian Hotz, Ph.D.
1095 NW 14th Ter
Miami, FL 33136
ghotz@med.miami.edu
305-243-2074

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, and BikeSafe programs.

Comparing Public vs. Private High School Sports-Related Concussions from a Countywide Concussion Injury Surveillance System

ABSTRACT

Purpose
Largely, research on adolescent sports-related concussion (SRC) has focused on public school athletes. SRCs of private school athletes have been studied less and may differ due to differences between school types.

Methods
SRCs between Miami-Dade County high school athletes at trained public (n = 1088), trained private (n = 272), and untrained private (n = 79) were compared. Outcomes included days between date of injury (DOI) and clinic date, days between DOI and post-injury ImPACT retest, days withheld, return to play (RTP), ImPACT baseline and post-injury retest completion, and academic accommodation status.

Results
Trained public and trained private groups had similar days between DOI and clinic date, days withheld, and percentage who RTP. Differences between the trained public and untrained private groups existed for RTP but not for days between DOI and clinic date or days withheld. Private group athletes were more likely to receive academic accommodations.

Conclusions
Public and private high schools trained on the same SRC protocol did not have significantly different outcomes. The untrained private schools, however, had worse outcomes compared to the public group.

Application In Sports
SRC outcomes in both public and private high schools may benefit from SRC education, training, an established protocol, and use of a management system.

Keywords: youth athletes, concussion recognition, concussion management, private schools, sports

INTRODUCTION

Each year, an estimated 1.6 to 3.8 million sports-related concussions (SRCs) occur in the United States (1). While the nearly 8 million high school athletes participating in sports annually benefit from the improved social, psychological, and physical health gained from playing sports (2, 3), there is also an ongoing risk of injury due to consistent athlete-exposure (4). SRCs are understandably a concern for high school aged athletes due to the short-term and potentially lifelong behavioral, cognitive, emotional, physical, and psychological effects they can produce (1, 5). These consequences can be particularly worrisome as this population is already experiencing their own ongoing physical and cognitive development changes that can negatively be affected by an SRC (6). Understanding risk factors contributing to adolescent SRCs and what may lead to differences in outcomes is therefore imperative for identifying those most at risk and ensuring the proper management and treatment resources are in place.

Thus far, an overwhelming majority of research on SRCs has focused on or included samples of public high school athletes as opposed to private high school athletes. One example is the High School Sports-Related Injury Surveillance Study, Reporting Information Online (RIO) (7). The High School RIO is an internet-based data collection tool that captures athletic exposures and injury events through athletic trainers (ATs) that report data. It is often used as a source of SRC data for research (4). In the most recent report, nearly 80% of the participating high schools were public with the rest being private (7). Additionally, other studies on SRC incidence and trends have included only athletes from public high schools (8.) The lack of private high school inclusion in adolescent SRC research is an important consideration because known distinctions between public and private high schools possibly lead to differences in SRC incidence and outcomes (4). These include differences in school size, support services and resources, student racial/ethnic backgrounds, rigorous academic programs, and socioeconomics (9).

While there has been recent research that details private high school athlete SRC experiences and reporting behavior (4, 10), there is still a need for continued research into private high school SRC outcomes. Specifically, it would be important to examine how SRC outcomes differ between public and private high schools. Therefore, the purpose of this study was to compare SRC outcomes between public high schools who received specific concussion training and education to private high schools who received the same training and private high schools who did not receive training on the same SRC protocol. The goal of using these three distinct groups was to examine whether differences in SRC outcomes would be a result of differences in SRC education, training, and protocol.

METHODS

Participants and Procedures

This study included Miami-Dade County (MDC) public and private high school athletes with an SRC that occurred in a practice or game between August 1^st, 2012, and July 31^st, 2022. All athletes were treated at the University of Miami Miller School of Medicine’s Concussion Clinic, UConcussion (UCC). Athletes that sustained an SRC outside of the study period were excluded as well as those with an SRC that did not occur during an MDC public or private high school practice or competition. If an athlete was treated at a provider other than the UCC, they were also excluded. 

 The UCC clinical team hosts an annual SRC training and educational workshop for MDC public high school ATs and athletic directors (ADs). In these workshops, ATs and ADs are trained on how to use the Six Steps to Play Safe protocol (11) and how to administer ImPACT (12) concussion tests. The UCC also makes available specialty concussion clinics where athletes with a suspected SRC can be referred to for management and treatment. The UCC similarly partners with and provides training and education to 8 private high schools within MDC. While athletes at other private high schools within MDC can still be referred to and receive treatment at the UCC, ATs and ADs at these high schools are not provided with the same educational workshops and training on the Six Steps to Play Safe protocol (11). In this study, there were 35 trained public, 8 trained private, and 29 untrained private high schools that were grouped as either “trained public,” “trained private,” or “untrained private,” respectively.              

The Six Steps to Play Safe (11) is a standardized protocol that can be used to manage an athlete’s SRC and safe return to play (RTP) and return to school during recovery (Figure 1). Included in this protocol are, in order, pre-season ImPACT (12) baseline testing, AT sideline testing, post-injury ImPACT testing, SRC clinic follow-up, gradual RTP and return to learn protocols, and SRC injury surveillance form completion.

Variables
Reported variables were collected during UCC visits and from surveillance reporting by ATs. Athlete information in the study included demographics and the sport played when the injury occurred. SRC specific information was also reported and included date of injury (DOI), days between DOI and first clinic date, days between DOI and post-injury ImPACT retest, RTP status (yes/no), and days between DOI and RTP (days withheld). To eliminate the few extreme outliers, athletes were only included in days between DOI and first clinic date as well as days withheld mean calculations if the value for these variables was < 120 days. For similar reasons, only athletes with days between DOI and post-injury ImPACT retest < 30 days were included in the calculation. Whether an athlete received academic accommodations was included as a variable because previous research (13) suggests that private high school students experience particularly high levels of stress due to concerns about academic performance and school requests, which potentially impacts whether academic accommodations are prescribed. The percentage of athletes who experienced loss of consciousness (LOC) was also reported because LOC indicates a potentially more severe SRC and is associated with longer recovery than SRCs without LOC (14). Athlete ImPACT (12) baseline testing and post-injury data from the ImPACT test online database was included and used to determine whether athletes had completed a baseline ImPACT test and/or a post-injury ImPACT retest. ImPACT testing comparisons were only included for the trained public and trained private high schools since untrained private high schools either did not use ImPACT or did not grant the UCC access to their records.

Data Analysis
Data analysis was performed using R 4.2.2. Athletes sustaining an SRC from MDC public high schools were compared with athletes from private schools between 2012-2022. The eight private schools were particularly selected because they followed a similar protocol and received the same SRC education as the public schools. The other 29 private schools did not receive the training or follow the protocol. For continuous data in the normal distribution like “Age”, mean and standard deviation were reported. For categorical data, such as “Gender”, data was presented as frequency and percentage. For those variables with important clinical significance, such as “Days withheld”, data was reported as median and interquartile range. Propensity score matching was performed to match the public schools with the eight private schools who received similar SRC training. SRC outcomes were therefore compared between trained public and trained private schools before and after matching. This was done to confirm whether one hypothesis, that public and private schools trained on the same SRC protocol would not differ in SRC outcomes, would be true when baseline covariates were and were not controlled for between the groups. Sample T-test was used to detect the significant difference for quantitative data in the normal distribution. The Wilcoxon test was used for quantitative data in non-normal distribution. The Chi-Square test was used to detect significant differences in categorical data. Statistical significance was set at < 0.05.

RESULTS

Participant Demographics
A total of 1,088 public, 272 trained private, and 79 untrained private athletes were treated at the UCC during the study period and are included in this study. The average age was similar for each group (16.5 and 16.2). While there were more male than female athletes in all three groups, the percentage of athletes that were female was greater in the trained (38.6%) and untrained (38.0%) private groups than the public group (25.9%). In both the trained and untrained private groups, a greater percentage of athletes were White (28.5% and 25.3%) or Hispanic (62.6% and 68.0%) compared to public athletes (8.0% White, 56.4% Hispanic). The public group instead had a greater percentage of Black athletes (30.9%) than the trained (24.7%) and untrained (6.7%) private groups. Across all three groups, football accounted for the greatest percentage of SRCs but was more prevalent in the public (58.3%) than both private groups (36.4% and 39.2%) (Table 1).

Comparing Trained Public and Trained Private High Schools SRCs
Data from trained public and trained private high schools was compared to determine if there were any differences in outcomes between public and private high schools that were trained using the same protocol and program. There were no differences between the groups for days between DOI and first clinic date (P = 0.1), days withheld (P = 0.83), post-injury retest completion (P = 0.06), and RTP (P = 0.30). The average days between DOI and post-injury ImPACT retesting was smaller (P < 0.001) for the public (3 days) than trained private (6 days) group. The public group also had a greater percentage of athletes who completed ImPACT baseline testing (88.5% vs. 80.1%; P < 0.001). The trained private group had a significantly greater percentage of athletes who had academic accommodations (P < 0.001) and experienced LOC (P < 0.001) (Table 2).

After matching, groups had similar demographic characteristics for age, sex, race, grade, and sport (Table 3). Outcomes between the matched groups were also compared, and there were no differences for days between DOI and first clinic date, days withheld, percentage of athletes who completed ImPACT baseline testing and post-injury retesting, and RTP (Table 4). However, average days between DOI and post-injury ImPACT retest was smaller for the public group (4 vs. 6 days, P < 0.001). The public-school group was also more likely to have experienced LOC (P < 0.001) and not receive academic accommodations (P < 0.001).

Comparing Trained Public and Untrained Private High School SRCs
Trained public and untrained private groups did not differ in average days between DOI and first clinic date (P = 0.40) or days withheld (P = 0.40). A significantly greater percentage of the public group did RTP (91.9% vs. 81.0%; P = 0.002). More of the athletes in the untrained private group received academic accommodations (P < 0.001) and experienced LOC (P < 0.001) than did the trained public group (Table 5).

Discussion

Understanding risk factors, whether demographical (e.g., sex, age) or injury event-related (e.g., sport, mechanism of injury), that are associated with differences in SRC outcomes are important for ensuring that those most at risk receive proper SRC treatment and resources. One potential risk factor that was explored in this study was whether an athlete was from a public or private high school. Historically, most research on SRC risk and outcomes has been conducted using public high school athletes (4). This study provides further insight into how SRC outcomes between high school athletes differ based on the type of school attended and if a dedicated SRC protocol and education can help mitigate any differences.

While football accounted for the greatest percentage of SRCs in all three groups, its contribution was roughly 20% percent more in the public group than both private groups. Other sports, including soccer, basketball, and volleyball, were more prevalent in both private school groups. The distribution of sport played during the SRC injury event likely differed between public and private groups because private schools offer a variety of sport options, like crew and sailing, that were not available at public schools. This availability may have impacted the popularity of sports and participation numbers as private school athletes had a greater number of sports to choose from.

To our knowledge, there is only one other study (15) that directly compares SRC experiences between public and private schools. In that study, private school athletes were twice as likely to report a history of SRC compared to public school athletes, but there was no difference in RTP timelines between athletes at the different types of school (15). While the current study did not compare history of SRC between school types, analysis was performed to compare rates of RTP. There was no significant difference between the trained public and trained private school groups for RTP percentage or days withheld (Table 2), similar to the other study that concluded no difference in RTP. After matching, there was still no difference in RTP percentage or days withheld between these groups (Table 4). The untrained private group, however, had significantly less athletes RTP than the trained public group (Table 5). The UCC is a specialized concussion program that provides comprehensive SRC management and treatment, but the program also provides continuing education and a standardized protocol to the trained public and private high schools to better identify, manage, and treat athletes with an SRC (11). Athletes at these participating trained high schools potentially benefited from the coordinated and structured care they receive as a result of these trainings and partnerships, which may have led to better RTP outcomes compared to the untrained private group. These results also suggest that SRC outcomes do not necessarily depend on school type and the systematic differences between public and private schools (4, 9), but instead on AT and AD SRC education and if an SRC protocol is in place and being followed. Additionally, these results also indicate the positive effect an available and established SRC program and protocol with clinicians trained on SRC management and treatment can have on SRC outcomes.
Another finding was that the trained public and untrained private groups did not differ in average days between DOI and first clinic date (Table 5). Systematic differences in socioeconomics between public and private high schools (9) may explain why the trained public group did not have significantly fewer average days between DOI and first clinic date than the untrained private group, which was the initial hypothesized result. There is well established evidence (16) that supports a relationship between socioeconomics and access to healthcare, and socioeconomic differences between school type may have led to barriers, including transportation, time, and costs, that delayed public athletes from getting into the UCC (17). Yet, there was also no difference between trained public and trained private groups for average days between DOI and first clinic date in both unmatched and matched comparisons (Tables 2 and 4), suggesting that UCC’s partnership with these schools and the flexibility it provides by offering both on-site and virtual appointments may have alleviated any potential differences. These findings also indicate that educating ATs and ADs on the risks of SRCs leads to quicker identification and subsequent appointments.

The percentage of athletes who received academic accommodations after an SRC was significantly greater for both the trained (unmatched and matched) and untrained private school groups compared to the trained public school group. During recovery from an SRC, athletes may have post SRC symptoms that can interfere with their ability to participate and function in the classroom setting (18). Consequently, return to learn protocols and academic accommodations are often provided to the athlete to help reintegrate them into classes but also prevent worsening symptoms (19, 20). Previous research (13) shows that private school students face a particularly high level of academic pressure, potentially due to more rigorous academic programs (9), which could explain why a greater percentage of private groups in this study received more academic accommodations. These additional academic accommodations may have been provided to reduce the burden private group athletes felt about their academic responsibilities or at the request of academic advisors employed at these schools. However, it is important to ensure that all athletes with a sustained SRC receive any appropriate and necessary academic accommodation, regardless of school type attended, to prevent further symptom development.

Limitations
This study is not without limitations. All participants in this study were athletes that attended a public or private high school in MDC. Results may not be generalizable to other playing levels, like youth, middle schools, and college, nor to public or private high schools in other counties. Additionally, while other counties may have their own SRC surveillance system, they may not have a program, such as the UConcussion program, that provides ATs with additional SRC training and encourages timely, accurate reporting. A larger sample population in all three groups would have also been beneficial and provided more evidence on the impact of SRC education and protocol on SRC outcomes in the high school setting.

CONCLUSIONS

Public and private high school groups trained on the same SRC protocol did not have significantly different SRC outcomes. The untrained private high school group, however, had worse SRC outcomes compared to the public school group, suggesting that SRC outcomes in the high school setting may benefit from education, training, and an established SRC protocol and program and not on whether the school is public or private.

Applications In Sport

An inherent risk of playing sports is injuries, and SRCs are a particularly concerning injury for high school athletes, especially those playing contact sports. Ensuring those responsible for helping to manage SRCs in high schools are educated about SRCs is important, and a collaborative approach to treating and managing SRCs has been recommended (20). As suggested by this study, all high school personnel involved with athletics should be offered SRC management training and education to help improve outcomes of those that sustain an SRC. Additionally, an SRC protocol, like the Six Steps to Play Safe (11), should be established and can include:

• Pre-season baseline testing, using computer-based tests such as ImPACT (12)
• Sideline testing after a potential SRC injury (SCAT5, Balance Error Scoring System (BESS), etc.)
• Post-testing after a suspected SRC (to compare neurocognitive scores to pre-season baseline tests)
• Clinic appointments with a healthcare professional trained in SRC who can evaluate tests and make recommendations
• Gradual RTP and return to learn protocol after the athlete has been examined by a professional and is asymptomatic
• Injury surveillance system reporting by ATs

ACKNOWLEDGEMENTS
The authors would like to thank: Dr. Kaplan and the UHealth Sports Medicine Clinic and Staff, the Division of Athletics and Activities for the Miami-Dade County Public Schools, all Miami-Dade County High School Certified Athletic Trainers, previous UConcussion team members, Dr Kester Nedd who served as medical director of the program from 2012 to 2019, current medical director Dr. Abraham Chileuitt, and The Miami Dolphin Foundation for supporting countywide ImPACT testing and educational workshops. We also want to thank David Goldstein and the Goldstein Family for the development of the Countywide Concussion Care Program and their initial and continued support. The project was supported by the University of Miami Clinical and Translational Science Institute.

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