Authors: Luis Gude, MD, Gillian Hotz, PHD

Corresponding Author:
Gillian Hotz Ph.D
Lois Pope LIFE Center – 1-40, (R-48)
1095 NW 14th Terrace
Miami, Florida 33136.
[email protected]
305-243-4004

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.

Increased Identification of Concussions in High School Wrestlers after Rule Change

ABSTRACT

Purpose: The purpose of this study is to report on concussions identified in high school wrestlers, and to compare the number of injuries before and after the National Federation of State High School Associations (NFHS) enacted a rule change prior to the start of the 2019-20 season that increased the amount of time that an appropriate health-care professional may use to evaluate for a suspected sport related concussion (SRC) from 30 seconds to 5 minutes during competition.

Methods: The subjects of this study were wrestlers from Miami Dade County public high schools who sustained a sports related concussion from August 2017 to March 2020, 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, post-injury ImPACT tests, and from patients who presented to the University of Miami Sports Concussion Clinic for evaluation.

Results: A total of 37 wrestlers were identified. The 2019-20 academic year accounted for the greatest number of injuries (17, 46%), including the highest number of injuries identified that occurred during competition and practice compared to previous years.

Conclusions: The increase in identified concussions in wrestlers in the 2019-20 season is likely multifactorial given increased knowledge, education, and training on SRC that is targeted to athletes, parents, coaches, and athletic trainers. The increase in the number of injuries identified during competition is also likely attributable to the rule change instituted by the NFHS prior to the start of the 2019-20 season.

Applications in Sport: It is important to identify sport related concussions when they occur so that these athletes may seek treatment and obtain proper clearance prior to return to play, which may decrease the risk of subsequent SRC and long-term sequelae of mild traumatic brain injuries. Our findings support the rule change instituted by the NFHS prior to the start of the 2019-20 season as this increased the amount of time that an appropriate health-care professional may use to evaluate for a suspected SRC and likely contributed to an increase in the number of SRC identified in wrestlers during competition.

Key words: concussion, wrestling, player safety, education

INTRODUCTION

Wrestling is one of the oldest known sports, with depictions of wrestlers being found in cave paintings in France dating back 15,000 years. (6)  Different styles of wrestling developed regionally throughout its history, with the modern sport now being dominated by Greco-Roman and freestyle internationally (30), and folkstyle in North American high schools. (14)

Wrestling is a popular sport among United States high school aged athletes. The National Federation of State High School Associations (NFHS) collects participation statistics in high school sports and reported 268,565 total participants in wrestling in the 2018-19 academic year. Wrestling was the 7th most popular sport among male high school athletes with 247,441 participants, a number that has been rather consistent since the NFHS first published its participation numbers for the 1969-70 academic year with 226,881 participants. The NFHS first reported 48 female participants in wrestling in 1980 and reported participation has increased steadily since then. For the 2018-19 academic year, 21,124 female wrestlers from 43 states were reported. (22, 23) Female participation in wrestling continues to reach new heights, with the first female wrestler winning an individual state championship in February 2020. (1)

The overall injury rate in high school wrestlers is high, estimated to be second amongst all sports based on visits to emergency departments in the United States (29) and an analysis of the High School Reporting Information Online (HS RIO) injury surveillance system. (7, 11-14, 17, 18, 25, 26, 31, 32) While the overall rate of sport related concussion (SRC) in wrestlers is low compared to other sports  (15, 27), it is the most common injury after sprains and strains, accounting for 11-15% of all wrestling related injuries in recent studies. (14, 33) Prior studies reported that SRC accounted for 1-8% of all wrestling related injuries, but these studies were conducted prior to the widespread adoption of concussion education and protocols and are therefore likely underestimated. (16, 24)

Since 2012, the UHealth Sports Concussion program has implemented a countywide concussion management program (CCP) in Miami-Dade County (MDC). A six-step protocol is applied to identify head injured youth athletes and monitor their recovery and is implemented by all 35 public high schools in the county. It includes yearly educational workshops for the athletic trainers (ATC), baseline ImPACT testing for student athletes, and collection of concussion injury data through the concussion injury surveillance system (CISS) with the goals of improving concussion injury prevention programs and management.  (10)

Prior to the start of the 2019-2020 season, the NFHS implemented a rule change that increased the amount of time that an appropriate health-care professional may use to evaluate for a suspected SRC from 30 seconds to 5 minutes. Over the last year, the UHealth Sports Concussion Program has observed an increase in the number of wrestlers that have sustained a SRC and treated its first female wrestler. The purpose of this study is to report on the number of SRC in wrestlers identified by the CISS over the last three academic years from a county-wide public-school system before and after this rule change was enacted.

METHODS

The subjects of this study were wrestlers from the 35 MDC public high schools in the CCP who sustained a SRC from August 2017 to March 2020, the end of the high school wrestling season. Subjects who attended private or charter schools, or high school in a different county were excluded. Approval for this study was obtained from the Miami-Dade County Public School Department of Athletics and University of Miami Institutional Review Board.

The subjects of this study were identified from the CISS database, which is compiled from ImPACT results, and two REDCap databases. ImPACT is a computer-based neurocognitive assessment used to help clinicians assess and manage concussions. Under the CCP, all athletes participating in contact sports in MDC public high schools undergo a baseline ImPACT prior to competing in their sport and take a post-injury ImPACT within 72 hours of a suspected SRC. The first REDCap database 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, is disqualified from participation, 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).

RESULTS

A total of 37 wrestlers with SRC were identified, 35 males and 2 females. The average age was 16 years, with athletes in their junior year sustaining the most injuries (13, 39%), followed by freshman (10, 30%). 73% of athletes identified as Hispanic. The highest number of injuries were reported in the 2019-20 academic year (17, 46%).

Table 1: Demographics
  N %
37
Age (mean, years) 16
School Year 33
Freshman 10 30%
Sophomore 5 15%
Junior 13 39%
Senior 5 15%
Race/Ethnicity 33
Black 5 15%
Hispanic 24 73%
White 4 12%
Gender 37
Female 2 5%
Male 35 95%
History of Concussion 7
No 2 29%
Yes 5 71%

The most common mechanism of injury for wrestlers sustaining a SRC was contact with the mat (16, 43%), followed by head-to-head contact with the opponent (9, 24%). Of the 37 subjects, 30 (81%) were cleared by a physician for return-to-play with an average time withheld from sport of 18.5 days, 8 (27%) of which had a prolonged recovery of >28 day. One subject was medically disqualified from competing in contact sports, and 6 (16%) subjects were lost to follow-up. Two of the athletes lost to follow-up had appointments with the UHealth Sports Concussion Clinic that could not be completed given the emergence of the COVID-19 pandemic.

Table 2: Description of Subjects
  N %
Mechanism of Injury 37
Contact with Mat 16 43%
Contact with Opponent 10 27%
     Knee 1 3%
     Head-to-head 9 24%
Unknown 11 30%
Academic Accommodations 33
No 23 70%
Yes 10 30%
Outcome 37
Cleared 30 81%
Medically Disqualified 1 3%
Lost to Follow-up* 6 16%
Time out of play (days) 30
Mean (SD) 18.5 (10.2)  
Median (25th%, 75th%) 16 (11, 28.3)  
Number > 28 days 8 27%

*Includes athletes who had follow-up appoints with the UHealth Sports Concussion Clinic that were cancelled with the emergence of the COVID-19 pandemic.

Overall, the number of identified injuries sustained during practice (16, 48%), and during competition (17, 52%) were similar. The 2019-20 academic year had the highest number of injuries, as well as the highest number of injuries sustained during competition and practice. The 2018-19 academic year was the only year where the number of identified injuries sustained during practice was greater than during competition.

Table 3: Injury Event by Academic Year
Academic Year Total Competition Practice Unknown
2017-18 11 6 5 0
2018-19 9 2 6 1
2019-20 17 7 7 3
37 16 17 4

DISCUSSION

In our report, wrestlers in their junior year of high school had the highest number of concussions, while seniors had the lowest. Seniors may have more experience in the sport and likely have better technique when wrestling, lowering their risk of injury. Juniors may have a higher number of injuries as they may be wrestling against athletes with more experience than they may have or are competing for starting positions. Freshmen wrestlers also had a higher number of injuries, which may be due to having little experience and poor technique, or due to participation in wrestle-offs to make the team. (33) The most common mechanism of injury for concussion in high school wrestlers was contact with the mat, followed by head-to-head contact. These findings are similar to those in previous studies. (9, 14)

The average time of recovery for high school wrestlers with SRC in our report was 18.5 days, similar to other studies where the majority of adolescents with SRC typically recover in about 2 weeks. (3, 8, 19, 35) Reports of those with SRC who develop persistent post-concussive symptoms lasting over 28 days has varied greatly, from 1.5% – 2.8% in high school athletes (20, 21) to 10-20% in all individuals. (5) Not only do individuals with prolonged recovery suffer from their concussive symptoms for a greater period of time, they are also at increased risk of long-term sequelae such mood changes, depression and behavior disorders (3). Given the increased participation of female athletes in wrestling, it is important to recognize that female patients with concussion report a higher initial symptom burden and are more likely to have a prolonged recovery compared to males. (4, 28, 34, 35) In our report 27% of wrestlers had a prolonged recovery of >28 days, suggesting that that the concussions that wrestlers sustain may be of higher grade when compared to other sports.

Our findings show that the 2019-20 academic year accounted for the greatest number of injuries (17, 46%), including the highest number of injuries identified that occurred during competition (7) and practice (7) compared to previous years. This is likely multifactorial given increased knowledge, education, and training on SRC that is targeted to athletes, parents, coaches, and athletic trainers. The increase in the number of injuries identified during competition is also likely attributable to the rule change instituted by the NFHS prior to the start of the 2019-20 season that increased the amount of time that an appropriate health-care professional may use to evaluate for a suspected SRC from 30 seconds to 5 minutes. However, the 2017-18 academic year also had a high number of injuries reported that occurred during competition (6), and our findings may reflect normal variation given the small sample size of three academic years.

It is important to allow for increased time to evaluate for concussion during a match because although a greater number of concussions in wrestlers occur during practice, the rate is highest during competition. (14, 27) Concussions also account for a larger percent of injuries sustained during competition compared to practice. (14) In addition, wrestling accounts for the 3rd highest number of catastrophic injuries in high school sports, with the majority (80%) of these injuries occurred during competition. (2)

Limitations

Our findings have several limitations. First, due to limited ATC availability and resources, we are unable to collect information on athletic exposure and are therefore unable to assess the rate of injury of SRC in wrestlers or by event type. Injuries sustained are likely underreported as most schools only have one ATC on staff who is responsible for overseeing all sports within a season and are reliant on the coaches or the athlete to report a suspected injury to them. In addition, submission of the surveillance report may be delayed, leading to incorrect data entry or incomplete datasets. 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 administered a post-injury ImPACT test or submitted the surveillance report. The data that the CISS captures could be improved by collecting more information specific to wrestling, such as if the injury was caused during a takedown or sparring or use of protective equipment like headgear or mouth guards.

CONCLUSIONS

Wrestling is a popular sport amongst male high school athletes and continues to develop and grow in popularity.  Concussion is a common injury in the sport, particularly during competition. Therefore, it is important to continue to include wrestling in sports related concussion protocols so that its participants may benefit from concussion education programs, resources for better facilities, and inclusion in injury surveillance systems. Our findings reflect the rule change instituted by the NFHS prior to the start of the 2019-20 season that increased the amount of time that an appropriate health-care professional may use to evaluate for a suspected SRC from 30 seconds to 5 minutes as this likely contributed to the increased number of reported SRC sustained by wrestlers in the 2019-20 season compared to previous seasons.

Future research should include collecting more long-term data on these athletes and encourage other high school wrestling programs to track their concussions in order to improve their concussion management protocols and knowledge of sports related concussions.

APPLICATION IN SPORT

It is important to identify sport related concussions when they occur so athletes may seek treatment and obtain proper clearance prior to return to play, which may decrease the risk of subsequent SRC and long-term sequelae of mild traumatic brain injuries. Our findings support the rule change instituted by the NFHS prior to the start of the 2019-20 season as this increased the amount of time that an appropriate health-care professional may use to evaluate for a suspected SRC and likely contributed to an increase in the number of SRC identified in wrestlers during competition.

ACKNOWLEDGMENTS

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 David Goldstein and his family for their continued support of the Countywide Concussion Program.

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