The Journal of Primary Prevention

, Volume 35, Issue 5, pp 309–319 | Cite as

Neck Strength: A Protective Factor Reducing Risk for Concussion in High School Sports

  • Christy L. Collins
  • Erica N. Fletcher
  • Sarah K. Fields
  • Lisa Kluchurosky
  • Mary Kay Rohrkemper
  • R. Dawn ComstockEmail author
  • Robert C. Cantu
Original Paper


As the number of high school students participating in athletics continues to increase, so will the number of sports-related concussions unless effective concussion prevention programs are developed. We sought to develop and validate a cost-effective tool to measure neck strength in a high school setting, conduct a feasibility study to determine if the developed tool could be reliably applied by certified athletic trainers (ATs) in a high school setting, and conduct a pilot study to determine if anthropometric measurements captured by ATs can predict concussion risk. In the study’s first phase, 16 adult subjects underwent repeated neck strength testing by a group of five ATs to validate the developed hand-held tension scale, a cost effective alternative to a hand-held dynamometer. In the second phase, during the 2010 and 2011 academic years, ATs from 51 high schools in 25 states captured pre-season anthropometric measurements for 6,704 high school athletes in boys’ and girls’ soccer, basketball, and lacrosse, as well as reported concussion incidence and athletic exposure data. We found high correlations between neck strength measurements taken with the developed tool and a hand-held dynamometer and the measurements taken by five ATs. Smaller mean neck circumference, smaller mean neck to head circumference ratio, and weaker mean overall neck strength were significantly associated with concussion. Overall neck strength (p < 0.001), gender (p < 0.001), and sport (p = 0.007) were significant predictors of concussions in unadjusted models. After adjusting for gender and sport, overall neck strength remained a significant predictor of concussion (p = 0.004). For every one pound increase in neck strength, odds of concussion decreased by 5 % (OR = 0.95, 95 % CI 0.92–0.98). We conclude that identifying differences in overall neck strength may be useful in developing a screening tool to determine which high school athletes are at higher risk of concussion. Once identified, these athletes could be targeted for concussion prevention programs.


Head injury Prevention Athlete Soccer Basketball Lacrosse 



We would like to thank Breg for generously donating the Velcro bands used in the developed neck strength tool. This study was funded by the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

Conflict of interest

The authors have no conflicts of interest to disclose.


  1. Broshek, D. K., Kaushik, T., Freeman, J. R., Erlanger, D., Webbe, F., & Barth, J. T. (2005). Sex differences in outcome following sports-related concussion. Journal of Neurosurgery, 102(5), 856–863.PubMedCrossRefGoogle Scholar
  2. Buzzini, S. R., & Guskiewicz, K. M. (2006). Sport-related concussion in the young athlete. Current Opinion in Pediatrics, 18(4), 376–382.PubMedCrossRefGoogle Scholar
  3. Centers for Disease Control and Prevention. (2007). Nonfatal traumatic brain injuries from sports and recreation activities: United States, 2001–2005. Morbidity and Mortality Weekly Report, 56(29), 733–737.Google Scholar
  4. Conley, M. S., Stone, M. H., Nimmons, M., & Dudley, G. A. (1997). Resistance training and human cervical muscle recruitment plasticity. Journal of Applied Physiology, 83, 2105–2111.PubMedGoogle Scholar
  5. Cross, K. M., & Serenelli, C. (2003). Training and equipment to prevent athletic head and neck injuries. Clinical Journal of Sport Medicine, 22, 639–657.CrossRefGoogle Scholar
  6. Darrow, C. J., Collins, C. L., Yard, E. E., & Comstock, R. D. (2009). Epidemiology of severe injuries among United States high school athletes 2005–2007. American Journal of Sports Medicine, 37(9), 1798–1805.PubMedCrossRefGoogle Scholar
  7. Dick, R. W. (2009). Is there a gender difference in concussion incidence and outcomes? British Journal of Sports Medicine, 43, i46–i50.PubMedCrossRefGoogle Scholar
  8. Dietz, W. H. (1998). Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics, 101, 518–525.PubMedGoogle Scholar
  9. Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002–2006. Atlanta, GA: CDC, National Center for Injury Prevention and Control. Retrieved from
  10. Field, M., Collins, M. W., Lovell, M. R., & Maroon, J. (2003). Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. Journal of Pediatrics, 142(5), 546–553.PubMedCrossRefGoogle Scholar
  11. Frommer, L. J., Gurka, K. K., Cross, K. M., Ingersoll, C. D., Comstock, R. D., & Saliba, S. A. (2011). Sex differences in concussion symptoms of high school athletes. Journal of Athletic Training, 46(1), 76–84.PubMedCentralPubMedCrossRefGoogle Scholar
  12. Gessel, L. M., Fields, S. K., Collins, C. L., Dick, R. W., & Comstock, R. D. (2007). Concussions among high school and college athletes. Journal of Athletic Training, 42(4), 495–503.PubMedCentralPubMedGoogle Scholar
  13. Mansell, J., Tierney, R. T., Sitler, M. R., Swanik, K. A., & Stearne, D. (2005). Resistance training and head-neck segment dynamic stabilization in male and female collegiate soccer players. Journal of Athletic Training, 40(4), 310–319.PubMedCentralPubMedGoogle Scholar
  14. McClincy, M. P., Lovell, M. R., Pardini, J., Collins, M. W., & Spore, M. K. (2006). Recovery from sports concussion in high school and collegiate athletes. Brain Injury, 20(1), 33–39.PubMedCrossRefGoogle Scholar
  15. National Federation of State High School Associations. (2012). 2011–2012 High school athletics participation survey. Retrieved from
  16. Pate, R. R., Pratt, M., Blair, S. N., Haskell, W. L., Macera, C. A., Bouchard, C., et al. (1995). Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. The Journal of the American Medical Association, 273, 402–407.CrossRefGoogle Scholar
  17. Patel, D. R., & Greydanus, D. E. (2002). Neurologic considerations for adolescent athletes. Adolescent Medicine, 13(3), 569–578.PubMedGoogle Scholar
  18. Patel, D. R., Shivdasani, V., & Baker, R. J. (2005). Management of sport-related concussion in young athletes. Sports Medicine, 35(8), 671–684.PubMedCrossRefGoogle Scholar
  19. Prasad, D. S., & Das, B. C. (2009). Physical inactivity: A cardiovascular risk factor. Indian Journal of Medical Sciences, 63, 33–42.PubMedCrossRefGoogle Scholar
  20. Rechel, J. A., Yard, E. E., & Comstock, R. D. (2008). An epidemiologic comparison of high school sports injuries sustained in practice and competition. Journal of Athletic Training, 43(2), 197–204.PubMedCentralPubMedCrossRefGoogle Scholar
  21. Salmon, D. M., Harrison, M. F., & Neary, J. P. (2011). Neck pain in military helicopter aircrew and the role of exercise therapy. Aviation, Space and Environmental Medicine, 82(10), 978–987.CrossRefGoogle Scholar
  22. Scorza, K. A., Raleigh, M. F., & O’Connor, F. G. (2012). Current concepts in concussion: Evaluation and management. American Family Physician, 85(2), 123–132.PubMedGoogle Scholar
  23. Shankar, P. R., Fields, S. K., Collins, C. L., Dick, R. W., & Comstock, R. D. (2007). Epidemiology of high school and collegiate football injuries in the United States, 2005–2006. American Journal of Sports Medicine, 35(8), 1295–1303.PubMedCrossRefGoogle Scholar
  24. Smith, D. W., Bailes, J. E., Fisher, J. A., Robles, J., Turner, R. C., & Mills, J. D. (2012). Internal jugular vein compression mitigates traumatic axonal injury in a rat model by reducing the intracranial slosh effect. Neurosurgery, 70(3), 740–746.PubMedCrossRefGoogle Scholar
  25. Tierney, R. T., Higgins, M., Caswell, S. V., Brady, J., McHardy, K., Driban, J. B., et al. (2008). Sex differences in head acceleration during heading while wearing soccer headgear. Journal of Athletic Training, 43(6), 578–584.PubMedCentralPubMedCrossRefGoogle Scholar
  26. Tierney, R. T., Sitler, M. R., Swanik, C. B., Swanik, K. A., Higgins, M., & Torg, J. (2005). Gender differences in head-neck segment dynamic stabilization during head acceleration. Medicine and Science in Sports and Exercise, 37(2), 272–279.PubMedCrossRefGoogle Scholar
  27. Viano, D. C., Casson, I. R., & Pellman, E. J. (2007). Concussion in professional football: Biomechanics of the struck player-part 14. Neurosurgery, 61, 313–328.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Christy L. Collins
    • 1
  • Erica N. Fletcher
    • 1
  • Sarah K. Fields
    • 2
  • Lisa Kluchurosky
    • 3
  • Mary Kay Rohrkemper
    • 4
  • R. Dawn Comstock
    • 5
    • 6
    Email author
  • Robert C. Cantu
    • 7
    • 8
    • 9
    • 10
    • 11
    • 12
  1. 1.Center for Injury Research and PolicyThe Research Institute at Nationwide Children’s HospitalColumbusUSA
  2. 2.Department of CommunicationUniversity of Colorado-DenverDenverUSA
  3. 3.Sports MedicineNationwide Children’s HospitalColumbusUSA
  4. 4.Central Ohio Primary CareColumbusUSA
  5. 5.Pediatric Injury Prevention, Education, and Research (PIPER) Program, Department of EpidemiologyColorado School of Public HealthAuroraUSA
  6. 6.University of Colorado School of Medicine, Pediatric Emergency MedicineAuroraUSA
  7. 7.Department of Neurology, Center for the Study of Traumatic EncephalopathyBoston University School of MedicineBostonUSA
  8. 8.Sports Legacy InstituteWalthamUSA
  9. 9.Department of NeurosurgeryBoston University School of MedicineBostonUSA
  10. 10.Department of NeurosurgeryEmerson HospitalConcordUSA
  11. 11.Department of SurgeryEmerson HospitalConcordUSA
  12. 12.Department of Neurosurgery, Neurologic Sports Injury CenterBrigham and Women’s HospitalBostonUSA

Personalised recommendations