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Effects of Youth Football on Selected Clinical Measures of Neurologic

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 Journal http://jcn.sagepub.com/
of Child Neurology

Effects of Youth Football on Selected Clinical Measures of Neurologic Function: A Pilot Study
Thayne A. Munce, Jason C. Dorman, Tryg O. Odney, Paul A. Thompson, Verle D. Valentine and Michael F. Bergeron
J Child Neurol published online 21 November 2013
DOI: 10.1177/0883073813509887

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Original Article
Journal of Child Neurology
201X, Vol XX(X) 1-7
Effects of Youth Football on Selected ª The Author(s) 2013
Reprints and permission:
sagepub.com/journalsPermissions.nav
Clinical Measures of Neurologic Function: DOI: 10.1177/0883073813509887
jcn.sagepub.com
A Pilot Study

Thayne A. Munce, PhD1,2,3, Jason C. Dorman, MS1,3,

Tryg O. Odney, MS, ATC4, Paul A. Thompson, PhD5,
Verle D. Valentine, MD, FACSM1,3,4,6, and
Michael F. Bergeron, PhD, FACSM1,2,3

Abstract
We assessed 10 youth football players (13.4 + 0.7 y) immediately before and after their season to explore the effects of football
participation on selected clinical measures of neurologic function. Postseason postural stability in a closed-eye condition was improved
compared to preseason (P ¼ .017). Neurocognitive testing with the Immediate Post-Concussion Assessment and Cognitive Testing
(ImPACT) battery revealed that reaction time was significantly faster at postseason (P ¼ .015). There were no significant preseason
versus postseason differences in verbal memory (P ¼ .507), visual memory (P ¼ .750), or visual motor speed (P ¼ .087). Oculomotor
performance assessed by the King-Devick test was moderately to significantly improved (P ¼ .047-.115). A 12-week season of youth
football did not impair the postural stability, neurocognitive function, or oculomotor performance measures of the players evaluated.
Though encouraging, continued and more comprehensive investigations of this at-risk population are warranted.

Keywords
balance, oculomotor, neurocognitive, subconcussive

Received June 30, 2013. Received revised September 05, 2013. Accepted for publication September 24, 2013.

Football players are exposed to numerous impact forces that
may cause the brain to become injured through direct or indi-
rect contact.1,2 Among boys, more concussions are attributable
to football than any other sport.3 Furthermore, football is the
leading cause of child and adolescent emergency room visits
associated with organized team sports.4 Although the vast
majority of head impacts in football do not result in a concus-
sion, the cumulative effect of the repetitive blows imparted to
the head in this sport is unknown.5,6 Of particular concern is the
potentially unrecognized damage that typical head impact
forces cause to the developing brains of children and adoles-
cents who play football.7
Neurologic deficits are known to be cumulative in athletes
who have experienced multiple concussions.8 Lasting effects
of subconcussive blows, however, are just recently being elu-
cidated. Postmortem investigations of former athletes who
participated in contact-collision sports have revealed evi-
dence of chronic traumatic encephalopathy.9 Using functional
magnetic resonance imaging (MRI), Talavage et al10 found
neurophysiological changes in the brains of high school foot-
ball players who had not suffered a concussion, and subse-
quently discovered that the functional MRI alterations in
this population were associated with the number of head
impacts sustained by these players.11 Additionally, temporary
impairments in learning among collegiate contact sport ath-
letes and deficits in certain measures of neurologic function
and/or balance among nonconcussed collegiate football play-
ers have also been reported.12,13 In contrast, a study of collegi-
ate football players demonstrated no change in mental status
or neurocognitive function, as assessed by the Standardized
Assessment of Concussion and Immediate Post-Concussion
1
National Institute for Athletic Health & Performance, Sanford Health, Sioux
Falls, SD, USA
2
Department of Pediatrics, University of South Dakota Sanford School of
3
Medicine, Sioux Falls, SD, USA
Sanford Research, Sioux Falls, SD, USA
4
Sanford Orthopedics & Sports Medicine, Sanford Health, Sioux Falls, SD, USA
5
Methodology and Data Analysis Division, Sanford Research, Sioux Falls, SD,
USA
6
Department of Family Medicine, University of South Dakota Sanford School
of Medicine, Sioux Falls, SD, USA
Corresponding Author:
Thayne A. Munce, PhD, National Institute for Athletic Health & Performance,
Sanford Health, 1210 W. 18th St., Suite 204, Sioux Falls, SD 57104, USA.
Email: thayne.munce@sanfordhealth.org

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2 Journal of Child Neurology XX(X)
Assessment and Cognitive Testing (ImPACT), over the
course of a season.14
There is evidence for an increased susceptibility to severe
concussive injuries and more protracted recovery in children and
adolescents compared to adults.15 For example, research has
shown that high school athletes who experienced a concussion
had longer recovery times in several assessments of memory
compared to concussed collegiate athletes.16 Normal intellectual
and social development may also be impeded in children and
adolescents who have experienced a concussion due to time
missed at school and/or behavioral changes resulting from the
injury.15 However, comprehensive preseason and postseason
clinical neurologic assessments of neurocognitive function, bal-
ance, symptom severity, and oculomotor performance have not
been reported for nonconcussed youth football players.
Considering an apparent heightened vulnerability of chil-
dren to serious brain injury and growing concern about the
chronic effects of concussions and subconcussive brain trauma
in football,9,17 the scarcity of neurologic research focused on
youth football is disconcerting. Therefore, as an initial step
toward exploring the effect of normal football participation
on the neurologic health of children, we assessed several
domains of neurologic function in a group of youth football
players before and after a football season. Specifically, our aim
was to determine if neurologic deficits consistent with the diag-
noses of mild traumatic brain injury could be detected in non-
concussed youth football players using standard clinical
measures. We hypothesized that no significant preseason to
postseason differences would be discovered among any of the
assessments. In addition to being the first investigation of its
kind in this age group, this study was piloted to examine the
specific protocols and overall feasibility and logistics of con-
ducting research with this subject population. These findings
would then set the stage for more comprehensive evaluations
and longitudinal tracking of these athletes.
Methods
Fifteen adolescent boys (13.4 + 0.7 y old) who were registered on a
single tackle football team were enrolled in this study. The subjects’
team participated in the seventh-eighth grade division of a local youth
football league. Two of the players voluntarily withdrew from the
team during the season and only completed preseason testing (lost
to follow-up). One additional player completed preseason and postsea-
son testing, but did not participate in the actual football portion of the
season. Two additional players suffered physician-diagnosed concus-
sions during the course of the season. Descriptive data from the 2 con-
cussed players have been included in this report, but the preseason
versus postseason analysis was limited to the 10 nonconcussed players
who participated throughout the entire season. The 3 players who quit
were younger on average (12.4 vs 13.5 y old) and had less experience
playing other contact sports (0/3 had previously played another con-
tact sport, whereas 6/12 of the remaining players had previously
played another contact sport). There was only a slight difference, how-
ever, in the number of years of previous football experience between
those who quit (1.3 y) and those who remained on the team (1.7 y).
The 2 concussed players had similar demographic characteristics as
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the rest of the players, though one of them was the youngest player
on the team.
Evaluations were performed before and after a 12-week season,
with approximately 13 weeks separating the test sessions. Preseason
testing was carried out during the first week of practice but prior to any
contact, whereas postseason testing was conducted within 1 week of
the last game. An identical battery of tests was performed at both test
sessions by the same group of investigators. This study was approved
by the Institutional Review Board of Sanford Health, Sioux Falls,
South Dakota. All subjects gave their written assent to participate and
their parents/guardians provided written informed consent.
Health History, Injury Surveillance, and Football Exposure
Medical/health history and concussion recall questionnaires were
administered to subjects and their parents/guardians at each test ses-
sion to retrospectively assess relevant injuries, particularly head
trauma and concussions. The team’s coach received leaguewide con-
cussion awareness and education training, and we regularly contacted
him for up-to-date injury reports throughout the season. The football
players’ individual football exposure was measured indirectly by
obtaining the coach’s practice attendance record.
Postural Stability
Testing for postural stability consisted of 2 separate static balance tests
performed on an AMTI strain gauge force platform (OR6-6, Newton,
MA) for a period of 20 seconds at a sampling rate of 100 Hz. For each
test, subjects stood with both feet on the force platform while attempt-
ing to be as steady as possible. Subjects performed the tests without
shoes, kept their heads in the neutral position, and had their hands
on their hips. The 2 balance test trials were (1) Eyes Open and (2) Eyes
Closed. Subjects’ center of pressure positional changes were tracked
and recorded using an integrated computer and diagnostic software
package (BioAnalysis). Specifically, a subject’s 95% ellipse area was
obtained from BioAnalysis on each trial and used as a marker of pos-
tural stability. This value is a measure of the elliptical area that con-
tains 95% of the horizontal positional coordinates of a subject’s
center of pressure. In effect, the 95% ellipse area measures a subject’s
postural sway over a period of time. We have shown good (intraclass
correlation coefficient: 0.53-0.63) test-retest reliability measures of
balance with this method in adolescents who have not suffered a
concussion.18
Oculomotor Performance
Oculomotor performance was assessed with the King-Devick test.19
The King-Devick test requires subjects to rapidly read single-digit
numbers off of a series of 3 cards. The arrangement and spacing of
numbers on each card are unique and progressively increase in reading
difficulty on each successive card. Subjects were given standard
instructions and were asked to read the numbers from left to right, top
to bottom, as rapidly as possible without making an error. The time to
complete each card was measured with a stopwatch to the nearest
tenth of a second, and the number of errors was noted. Subjects were
given up to 3 attempts to complete each card without an error. This
allowed us to obtain an accurate representation of the subjects’ max-
imum oculomotor performance on this test that was not inhibited by a
single stumble or error. The fastest time without an error was recorded
for each card, and those times were summed for a best total time on all
3 cards. Test-retest reliability for this test has been reported as being
Munce et al 3

very high among nonconcussed adults, with an intraclass correlation Table 1. Preseason and Postseason Neurologic Testing Results in
coefficient of 0.97 (95% confidence interval ¼ 0.90-1.0),20 although Youth Football Players (n ¼ 10).
a mild learning effect has also been observed.21
Assessment Preseason valuea Postseason valuea

Neurocognitive Function Balance (95% COP ellipse area)

Eyes Open 1.68 + 1.27 1.58 + 1.41
Computer-based neurocognitive testing was conducted using the Eyes Closed 3.33 + 2.31 1.72 + 1.38*
ImPACT program (online version), a widely used, commercially avail- King-Devick Test (sec)
able software package for concussion assessments.22 ImPACT consists KD-1 14.63 + 1.80 13.18 + 1.31*
of a test battery measuring various domains of neurocognitive function: KD-2 15.30 + 2.59 13.80 + 1.28
Reaction Time, Visual Motor Speed, Verbal Memory, and Visual Mem- KD-3 17.42 + 3.47 15.56 + 2.09
ory. An absolute composite score is generated for each of these neuro- KD-TOT 47.35 + 7.41 42.54 + 4.32
cognitive domains and can be compared with normative data. More ImPACT Composite Scores
detailed information about ImPACT can be found in Schatz et al.23 Reaction Time 0.58 + 0.04 0.54 + 0.04*
Intraclass correlation coefficients for test-rest reliability of the online Verbal Memory 80.20 + 9.73 82.60 + 12.56
version of ImPACT have been reported as 0.76 for Reaction Time, Visual Memory 74.00 + 6.39 72.40 + 17.47
0.85 for Visual Motor Speed, 0.62 for Verbal Memory, and 0.70 for Visual Motor Speed 34.82 + 6.40 36.50 + 6.15
Visual Memory.24 Symptom Score (PCSS) 2.30 + 2.54 1.20 + 1.03
Each baseline (preseason) ImPACT evaluation was screened for
Abbreviations: COP, center of pressure; ImPACT, Immediate Post-Concussion
invalid effort using the automated internal checks available with this Assessment and Cognitive Testing; KD-1, King-Devick test card 1; KD-2, King-
software. One subject was flagged and repeated the test, which was Devick test card 2; KD-3, King-Devick test card 3; KD-TOT, King-Devick test
determined to be valid on the second attempt. At each session, subjects total; PCSS, Post-Concussion Symptom Scale.
a
completed ImPACT first, whereas the remaining assessments were Data represent mean + standard deviation.
performed in random order. *Significantly different from preseason value (P < .05).

Symptom Scores
Self-reported symptom scores were obtained by implementing the Post-
Concussion Symptom Scale, a standardized assessment tool consisting
of 22 symptoms associated with a concussion that are rated for severity
on a 7-point Likert-type scale.25 Although the Post-Concussion Symp-
tom Scale is a component of the computerized Immediate Post-
Concussion Assessment and Cognitive Testing battery, for this study,
players were also led through the symptom scale separately by an ath-
letic trainer experienced in assessing patients in this manner.
Statistical Analysis
Preseason and postseason differences were analyzed using PROC
MIXED in SAS Version 9.2 (SAS Institute, 2009) for repeated mea-
sures. Repeated measures analysis using PROC MIXED is equivalent
to a paired t-test when 2 paired measures are used. Each variable of
interest was examined separately. All data are expressed as mean +
standard deviation. Level of significance for all comparisons was set
as a <.05. As this was a preliminary pilot examination with limited
access to players, no power analysis was performed. Rather, the results
here are designed to provide preliminary data for power analyses for
subsequent studies, in a strictly exploratory manner.
Results
At the beginning of the season, none of the football players who
completed the preseason assessment reported a prior occur-
rence of a concussion. However, 2 players experienced a con-
cussion during the season. Both of these injuries occurred while
playing football and were clinically diagnosed by a physician.
One of the players who suffered a concussion was not cleared
to return to play before the end of the season.
The number of practice sessions for the 10 nonconcussed
players who completed preseason and postseason testing
ranged from 19 to 32, with a mean of 25.8 sessions. The 2 con-
cussed players each participated in 20 practice sessions, and the
3 players who quit the team participated in an average of 3.3
practice sessions (range ¼ 0-7 sessions). Primary outcome
measurements for all assessments are shown in Table 1 (values
and analyses are limited to the 10 nonconcussed players who
remained on the team the entire season). Postural stability, as
indicated by the 95% Ellipse Area, was similar at both time
points in the Eyes Open condition (P ¼ .706). However, post-
season postural stability in the Eyes Closed condition was sig-
nificantly improved compared to the preseason (P ¼ .017).
There were individual variations in preseason to postseason
changes in 95% Ellipse Area among the players. In the Eyes
Open condition, 4/10 players had a smaller 95% Ellipse Area
(indicating improved postural stability) at the postseason eva-
luation, whereas in the Eyes Closed condition, 7/10 players had
a smaller 95% Ellipse Area. None of the postseason differences
in 95% Ellipse Area were greater than 1 standard deviation
(based on preseason values) above that individual’s preseason
measure(s).
Evaluation of oculomotor performance using the King-Devick
test revealed that reading time on King-Devick card 1 was
significantly faster during the postseason (P ¼ .047) and also
approached being significantly improved on King-Devick
card 2 and the King-Devick Total (P ¼ .071 and P ¼ .055,
respectively). On an individual basis, 8/10, 6/10, and 8/10 of the
players had faster postseason times on King-Devick card 1, card
2, and card 3, respectively. None of the times that were slower
during the postseason evaluation were more than 1 standard
deviation (based on preseason values) higher than that individu-
al’s preseason score.
Indicators of neurocognitive function assessed with ImPACT
showed variable changes. Reaction Time significantly improved

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4 Journal of Child Neurology XX(X)
from preseason to postseason (P ¼ .015), whereas there were no
significant temporal differences in Verbal Memory, Visual
Memory, or Visual Motor Speed (P ¼ .507, P ¼ .750, P ¼
.087, respectively). One player had a single preseason to postsea-
son composite score difference (Visual Memory) greater than
the reliable change index that has been reported for high
school athletes using this test battery.24 However, this player’s
postseason scores were improved on all other ImPACT compo-
site measures and his balance and King-Devick test results did
not reveal any sign of impairment. All other individual differ-
ences in preseason to postseason ImPACT composite scores
were improvements or smaller than the reliable change indices.
Concussion symptom scores evaluated by a certified athletic
trainer were low during both preseason (2.3 + 2.5) and post-
season (1.2 + 1.0) evaluations and were not significantly dif-
ferent (P ¼ .146) from each other. Similar results were found
when examining the identical symptom score battery on the
ImPACT evaluation (preseason: 2.7 + 2.9; postseason: 1.2
+ 2.5; P ¼ .285). There was also no association between indi-
vidual football exposure and any measure of neurologic func-
tion or symptom score.
The 2 concussed players performed their postseason assess-
ments at 22 (concussed player 1) and 80 (concussed player 2)
days postinjury. In both players, postseason postural stability
had improved or was within 1 standard deviation (see Table 1)
of their preseason measure(s) (concussed player 1: 1.202 vs
0.848 cm2 [Eyes Open], and 0.991 vs 2.170 cm2 [Eyes Closed];
concussed player 2: 0.279 vs 1.045 cm2 [Eyes Open], and 1.297
vs 0.513 cm2 [Eyes Closed]; preseason vs postseason). Read-
ing times on all 3 King-Devick cards were faster for both sub-
jects at the postseason assessment (concussed player 1: 17.20
vs 15.00 s [card 1], 19.40 vs 16.47 s [card 2], and 19.70 vs
16.38 s [card 3]; concussed player 2: 17.00 vs 14.79 s [card
1], 18.10 vs 15.66 s [card 2], and 18.30 vs 17.64 s [card 3]; pre-
season vs postseason). ImPACT scores had improved on 3 of
the 4 composite measures for concussed player 1 (99 vs 93
[Verbal Memory], 88 vs 90 [Visual Memory], 28.48 vs 34.65
[Visual Motor Speed], and 0.64 vs 0.63 [Reaction Time]; pre-
season vs postseason). Raw ImPACT scores were slightly
worse in 3 of the 4 composite measures for concussed player
2, but all deficits were well within the reliable change indices
for these categories (83 vs 76 [Verbal Memory], 75 vs 71
[Visual Memory], 37.85 vs 37.28 [Visual Motor Speed], and
0.84 vs 0.54 [Reaction Time]; preseason vs postseason).
Discussion
The primary finding of this study is that there were no observed
impairments in selected clinical measures of neurologic function
in these 10 youth football players tested before and after a 12-
week season. There were, in fact, significant improvements in
some measures of postural stability, oculomotor performance,
and neurocognitive function. Two players were concussed dur-
ing the season, but the clinical assessments used provided no
indication of neurologic deficit by the end of the season.
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Impaired postural stability (balance) is one of the principal
physiological functions that may be compromised in athletes
following head trauma.26 Balance in healthy individuals is
maintained by properly integrating visual, vestibular, and
somatosensory cues, but with concussed athletes, the areas of
the brain responsible for integrating these cues and maintaining
postural control may be temporarily disrupted or provide
improper information. Specific sensory input can be isolated
by minimizing the contribution of 1 or more of the other com-
ponents (eg, isolating primary vestibular and somatosensory
inputs by closing the eyes).27 Most commonly used field tests
are not sensitive enough to accurately assess postural stability
changes in athletes who have suffered head trauma.28 However,
with the aid of a force platform, subtle changes in balance can
be detected with greater precision.
Balance has been found to be acutely impaired following a
concussion in high school and collegiate football players.29 Such
deficits in postural stability typically persist for 3 to 5 days fol-
lowing a concussion, though limited data exist on the effect of
subconcussive football impacts on a player’s balance and pos-
tural stability. It may be that repeated subconcussive blows can
be cumulative and similarly capable of causing balance deficits
in individuals who have not suffered a concussion. However, the
duration of any such potential impairment is unknown.
Our results indicate that normal bipedal postural stability,
assessed by center of pressure excursion while standing on a
force platform, was unchanged in adolescent football players fol-
lowing a 12-week football season. However, when tested with
their eyes closed, postural stability was significantly improved
in these players after the season. This finding suggests either a
practice effect or an augmentation of the vestibular and/or soma-
tosensory components of balance during the football season. In
support of the latter, generalized improvements in balance asso-
ciated with participation in sports and/or exercise training pro-
grams have been reported.30 Thus, the neuromuscular activity
and physical demands inherent to football may have provided
a stimulus sufficient to augment postural control in these players.
The King-Devick test was developed as an assessment of
oculomotor performance for school-age children.19 More
recently, it has been proposed as a field-based indicator of brain
function in contact-collision sport athletes, showing reasonable
diagnostic abilities in mixed martial arts fighters and rugby
players.20,31 The football players in our study improved their
reading times modestly on all 3 of the King-Devick cards,
reaching statistical significance on King-Devick card 1. These
findings suggest that the aspects of oculomotor performance
measured by King-Devick were at least as good or better in the
youth football players after their season. Consistent with this
indication of improvement, Jafarzadehpur et al32 found greater
saccadic eye movement in advanced and intermediate volley-
ball players compared to beginning and nonplayers; however,
extensive research specific to oculomotor performance and
sports participation is limited.
Although there is rationale to support the game of football
having a direct influence on oculomotor performance, it is also
very likely that the slight improvement in this assessment was
Munce et al
associated with (prompted by) concomitant academic activities
of the players during the season. Preseason testing was con-
ducted 2 weeks prior to the beginning of the school year,
whereas postseason testing occurred during the 11th week of
the school year. Although reading activities were not measured
in this group, it is reasonable to expect that the players read
more during the school year and this activity provided a stimu-
lus for improvements in oculomotor performance. Finally,
another explanation for the improvements in King-Devick test
times that cannot be discounted is the possibility of a mild
learning effect. In fact, Galetta et al found that postseason
King-Devick test times were faster than baseline times among
a cohort of collegiate student-athletes, although athletes who
suffered a concussion during the season performed worse.21
It may be that the King-Devick test is effective at screening for
concussions by identifying impaired eye movements and sac-
cades but has limited utility in tracking changes in oculomotor
performance in noninjured individuals.
Computerized neurocognitive testing using the ImPACT
has been widely recognized and used as a clinical diagnostic
tool for evaluating brain injury in football and other contact-
collision sports.22 Most commonly, baseline testing is per-
formed at the beginning of a season followed by retesting
after head trauma and a resulting concussion. Scores from the
online version of the ImPACT have been shown to have good
stability over 1 year in high school athletes24 and over 2 years
in college athletes.33 ImPACT scores are also specific and
sensitive to neurocognitive and neurobehavioral conse-
quences of concussion in athletes.23
Among a group of collegiate football players who did not suf-
fer a concussion, Miller et al14 reported finding no deficits in any
ImPACT domain during preseason, midseason, and postseason
evaluations. As in that investigation, the adolescent football
players in our study had a statistically significant improvement
in the Reaction Time composite score from preseason to postsea-
son. However, the absolute difference in these scores (0.04 s)
was within the range identified as a reliable change in this com-
posite measure among high school athletes.24 Still, it is possible
that playing football contributed to generalized augmentations in
reaction time. Consistent with this assertion, it has been shown
that reaction times are improved following relatively short peri-
ods of exercise training or are better among athletes when com-
pared to a similar group of nonathletes.34,35
Limitations
This research has several limitations. First, the results pre-
sented here are based on an exploratory analysis of 10 youth
football players from the same team and are not intended to
be generalized; but rather, these findings provide initial insight
into this understudied population and establish preliminary
data for a more comprehensive study. A larger and/or more het-
erogeneous sample may have yielded different results. Second,
head impact exposure of the players in this study was not
assessed, so it is unclear what head trauma–related forces the
players experienced that may have affected brain function. A
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5
recent study indicated that youth football players, though much
younger than those we evaluated, had lower overall head
impact exposures than what had previously been reported for
high school and collegiate football players, yet the highest
magnitude forces approached those measured in the older
groups.2
Our study was designed to evaluate clinically relevant
changes in selected aspects of neurologic function that may
have resulted from cumulative impacts over the course of a
football season. Although the clinical measurements we used
did not reveal impairments in postural stability, neurocognitive
function, oculomotor performance, or greater symptom sever-
ity in our subjects, there could have been acute changes
throughout the season that had resolved by the time of our post-
season assessments. In-season evaluations more proximal to
games or practice sessions would be valuable for investigating
potential alterations in brain function of an acute nature. It is
also possible that unfavorable changes in brain anatomy and/
or function occurred during the season, but our evaluation
methods were not sensitive enough to detect them. More
sophisticated imaging techniques, such as functional MRI and
diffusion tensor imaging, could be employed in the future to
probe for neurophysiological indicators of damage.
Finally, improvements in postural stability, oculomotor per-
formance, and reaction time could all have resulted from a
learning effect subsequent to the preseason trial. However, the
important implication of these findings is that all of the mea-
sures of neurologic function remained unchanged or improved,
and deficits were not apparent. From a clinical standpoint,
these results suggest that nonconcussed players of this age who
perform worse on postseason assessments would be candidates
for further evaluation.
Summary
In conclusion, selected clinical measures of neurologic func-
tion were not adversely affected in 10 youth football players
tested before and after a 12-week season. There were, however,
significant improvements in some measures of postural stabi-
lity, oculomotor performance, and reaction time. Self-
reported concussion-related symptom severity was unchanged.
Of the 12 study participants who remained on the team
throughout the entire season, 2 experienced a concussion dur-
ing the course of the study and were excluded from the presea-
son versus postseason analysis. However, the selected clinical
measures used in this research did not reveal obvious neurolo-
gic deficits in either of these players by the end of the season.
This pilot investigation is the first study to report that non-
concussed youth football players do not exhibit clinically
recognized signs of neurologic impairment following a normal
playing season. Although these results are encouraging, more
subtle indices of brain injury may be discovered with advanced
imaging techniques and/or more precise clinical assessments.
Moreover, football-related neurologic damage and impairment
may be isolated to certain individuals and may not be apparent
in a groupwise analysis. Accordingly, we plan to advance this
6 Journal of Child Neurology XX(X)
research using a larger number of participants and investigate
the association of measured head impact exposure with individ-
ual changes in neurologic function over 1 or more seasons. The
rapidly evolving recognition and understanding of adverse con-
sequences of head trauma in football warrants continued and
more comprehensive study of this at risk population.
Acknowledgments
The authors thank Ashley Miller, MPH for assisting with the statistical
analysis, as well as Roxane Fouberg, MS, ATC, and Hannah Nelson,
MS, RD, for their assistance with data collection. Finally, the authors
sincerely thank our research volunteers and their parents for their par-
ticipation in this study and also greatly appreciate the support of this
project by South Dakota Junior Football, Inc.
Author Contributions
TAM contributed to the concept, design, data collection, data analysis,
and construction of the final draft of the article. JCD contributed to the
concept, design, data collection, data analysis, and review of the final draft
of the article. TOO contributed to the concept, data collection, and
approved the final draft of the article. PAT contributed to the design, data
analysis, and review of the final draft of the article. VDV contributed to
the concept, design, data collection, and review of the final draft of the
article. MFB contributed to the concept, design, and review of the final
draft of the article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the
research, authorship and/or publication of this article: The authors
received financial support for this study from Sanford Research, Sioux
Falls, South Dakota.
Ethical Approval
This research was approved by the Institutional Review Board of San-
ford Health, Sioux Falls, South Dakota (protocol number: 03-11-062).
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