Cited by 327Traumatic Brain Injury ResearchSports injuries and preventionAutomotive and Human Injury Biomechanics

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

Collins, Christy L., Fletcher, Erica N., Fields, Sarah K., Kluchurosky, Lisa, Rohrkemper, Mary Kay, Comstock, R. Dawn, Cantu, Robert C.·2014·The Journal of Primary Prevention

DOI 10.1007/s10935-014-0355-2

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Abstract

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.

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Mechanisms of Injury as a Diagnostic Predictor of Sport-Related Concussion Severity in Football, Basketball, and Soccer
Zuckerman, S. L., Totten, D. J., Rubel, K. E., Kuhn, A. W., Yengo-Kahn, A. M., & Solomon, G. S. (2016) · Neurosurgery · doi:10.1227/neu.0000000000001280 · Cited by 30
“An earlier study found that among men’s and women’s high school soccer, basketball, and lacrosse players, the risk of concussion was reduced by 5% for every pound of increased neck strength.(46) Further study is needed to empirically demonstrate a relationship between activation of the cervical musculature and the sev…”
Background
Epidemiologic comparisons of soccer-related injuries presenting to emergency departments and reported within high school and collegiate settings
Kerr, Z. Y., Pierpoint, L. A., Currie, D. W., Wasserman, E. B., & Comstock, R. D. (2017) · Injury Epidemiology · doi:10.1186/s40621-017-0116-9 · Cited by 27
“Previously (Collins et al. 2014), a study with high school students found that increased neck strength was associated with a decreased odds of concussion.”
BackgroundSelf-citation
Incidence and characteristics of injury in under-19 academy level rugby league match play: A single season prospective cohort study
Tee, J. C., Till, K., & Jones, B. L. (2018) · Journal of Sports Sciences · doi:10.1080/02640414.2018.1547100 · Cited by 27
“, 2018), while it has also been demonstrated that well-developed physical qualities are protective against injury in contact sports (Collins et al., 2014; Gabbett et al., 2012).”
Background
The efficacy of a movement control exercise programme to reduce injuries in youth rugby: a cluster randomised controlled trial
Hislop, M., Stokes, K., Williams, S., McKay, C., England, M., Kemp, S. P. T., & Trewartha, G. (2016) · BMJ Open Sport & Exercise Medicine · doi:10.1136/bmjsem-2015-000043 · Cited by 25
“Recent evidence proposes that neck strength is a modi ﬁ able risk factor for concussion, 96 with Collins et al 97 demonstrating that an inverse relationship may exist between concussion risk and neck strength.”
Background
Assessing Head/Neck Dynamic Response to Head Perturbation: A Systematic Review
Flao, E. L., Brughelli, M., Hume, P. A., & King, D. A. (2018) · Sports Medicine · doi:10.1007/s40279-018-0984-3 · Cited by 27
Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment
Schneider, K., Emery, C. A., Black, A. M., Yeates, K. O., Debert, C. T., Lun, V. M. Y., & Meeuwisse, W. H. (2019) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2019.8926 · Cited by 28
Automatic measurement of anthropometric dimensions using frontal and lateral silhouettes
Aslam, M., Rajbdad, F., Khattak, S., & Azmat, S. (2017) · IET Computer Vision · doi:10.1049/iet-cvi.2016.0406 · Cited by 20
Dependency of Head Impact Rotation on Head-Neck Positioning and Soft Tissue Forces
Fanton, M., Kuo, C., Sganga, J., Hernandez, F., & Camarillo, D. B. (2018) · IEEE Transactions on Biomedical Engineering · doi:10.1109/tbme.2018.2866147 · Cited by 27
“The strongest clinical evidence linking neck strength to TBI is a prospective study which found a modest negative correlation between neck strength and concussion in a large group of high school athletes [13].”
Background
Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion
Baker, M., Quesnele, J. J., Baldisera, T., Kenrick-Rochon, S., Laurence, M., & Grenier, S. G. (2019) · Musculoskeletal Science and Practice · doi:10.1016/j.msksp.2019.04.002 · Cited by 26
Predicting Risk of Sport-Related Concussion in Collegiate Athletes and Military Cadets: A Machine Learning Approach Using Baseline Data from the CARE Consortium Study
Castellanos, J. P., Phoo, C. P., Eckner, J. T., Franco, L. M., Broglio, S. P., McCrea, M., McAllister, T. W., & Wiens, J. (2020) · Sports Medicine · doi:10.1007/s40279-020-01390-w · Cited by 30
The role of cervical muscles in mitigating concussion.
Eckersley, C., Nightingale, R., Luck, J. F., & Bass, C. (2019) · Journal of Science and Medicine in Sport · doi:10.1016/j.jsams.2019.01.009 · Cited by 17
Neck Muscle Strength Training in the Risk Management of Concussion in Contact Sports: Critical Appraisal of Application to Practice
Storr, I. G. M. (2015) · Journal of Athletic Enhancement · doi:10.4172/2324-9080.1000195 · Cited by 25
“[14] obtained pre-season measures of peak isometric neck strength for 6,662 high school athletes.”
BackgroundMethodInfluential
Mild Jugular Compression Collar Ameliorated Changes in Brain Activation of Working Memory after One Soccer Season in Female High School Athletes
Yuan, W., Dudley, J. A., Foss, K. D. B., Ellis, J. D., Thomas, S. M., Galloway, R. T., DiCesare, C. A., Leach, J. L., Adams, J. M., Maloney, T., et al. (2018) · Journal of Neurotrauma · doi:10.1089/neu.2017.5262 · Cited by 26
Presence of Neck or Shoulder Pain Following Sport-Related Concussion Negatively Influences Recovery
Provance, A. J., Howell, D. R., Potter, M. N., Wilson, P. E., D’Lauro, A. M., & Wilson, J. C. (2020) · Journal of Child Neurology · doi:10.1177/0883073820909046 · Cited by 24
Head injuries in children′s football—results from two prospective cohort studies in four European countries
Faude, O., Rößler, R., Junge, A., der Fünten, K. A., Chomiak, J., Verhagen, E. A. L. M., Beaudouin, F., Dvořák, J., & Feddermann‐Demont, N. (2017) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.12839 · Cited by 23
The Effect of Muscle Activation on Head Kinematics During Non-injurious Head Impacts in Human Subjects
Reynier, K. A., Alshareef, A., Sánchez, E. J., Shedd, D. F., Walton, S. R., Erdman, N. K., Newman, B. T., Giudice, J. S., Higgins, M., Funk, J. R., et al. (2020) · Annals of Biomedical Engineering · doi:10.1007/s10439-020-02609-7 · Cited by 23
The Effects of Helmet Weight on Hybrid III Head and Neck Responses by Comparing Unhelmeted and Helmeted Impacts
Jadischke, R., Viano, D. C., McCarthy, J., & King, A. I. (2016) · Journal of Biomechanical Engineering · doi:10.1115/1.4034306 · Cited by 23
“[22] found that neck strength was a significant predictor of concussion in high school athletes.”
Background
Sex Differences in the Outcomes of Mild Traumatic Brain Injury in Children Presenting to the Emergency Department
Yeates, T. M., Taylor, H. G., Bigler, E. D., Minich, N. M., Tang, K., Cohen, D. M., Bacevice, A. M., Mihalov, L. K., Bangert, B. A., Zumberge, N. A., et al. (2021) · Journal of Neurotrauma · doi:10.1089/neu.2020.7470 · Cited by 25
“have smaller neck circumferences, smaller neck to head circumference ratios, and weaker neck strength (Eckner, Oh, Joshi, Richardson, & Ashton-Miller, 2014; Collins et al., 2014).”
Physical Conditioning Strategies for the Prevention of Concussion in Sport: a Scoping Review
Garnett, D., Patricios, J., & Cobbing, S. (2021) · Sports Medicine - Open · doi:10.1186/s40798-021-00312-y · Cited by 22
“2014 [27] Neck strength—yes Neck size—yes Soccer Basketball Lacrosse Unspecified n = 6704 (total) Male and female Eckner et al.”
BackgroundInfluential
Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma
Enniss, T. M., Basiouny, K., Brewer, B. L., Bugaev, N., Cheng, J. D., Danner, O. K., Duncan, T. K., Foster, S., Hawryluk, G. W. J., Jung, H. S., et al. (2018) · Trauma Surgery & Acute Care Open · doi:10.1136/tsaco-2017-000153 · Cited by 21
Neck and Trunk Strength Training to Mitigate Head Acceleration in Youth Soccer Players
Müller, C., & Zentgraf, K. (2020) · The Journal of Strength and Conditioning Research · doi:10.1519/jsc.0000000000003822 · Cited by 20
“A recent systematic review and an epidemiological study both demonstrated that neck strength is a significant predictor of concussions in youth athletes (10,40).”
Background
The effects of vision training, neck musculature strength, and reaction time on concussions in an athletic population
Honda, J., Chang, S. H., & Kim, K.-J. (2018) · Journal of Exercise Rehabilitation · doi:10.12965/jer.1836416.208 · Cited by 20
“The tools used to measure neck girth include cloth (Collins et al., 2014) and ultrasound (Schmidt et al., 2014) with both tools being a viable way to measure neck girth.”
Influential
Head and Neck Characteristics as Risk Factors For and Protective Factors Against Mild Traumatic Brain Injury in Military and Sporting Populations: A Systematic Review
Cooney, N. J., Sowman, P. F., Schilaty, N. D., Bates, N. A., Hewett, T. E., & Doyle, T. L. A. (2022) · Sports Medicine · doi:10.1007/s40279-022-01683-2 · Cited by 19
“[10] followed 6662 high school athletes (lacrosse, football/soccer, and basketball) throughout the 2010 and 2011 academic years.”
BackgroundMethodInfluential
Poor cervical proprioception as a risk factor for concussion in professional male rugby union players
Farley, T., Barry, E., Bester, K., Barbero, A., Thoroughgood, J., de Medici, A., Sylvester, R. J., & Wilson, M. G. (2022) · Physical Therapy in Sport · doi:10.1016/j.ptsp.2022.03.010 · Cited by 18
Head Impact Exposure in Practices Correlates With Exposure in Games for Youth Football Players
Bellamkonda, S., Woodward, S. J., Campolettano, E. T., Gellner, R. A., Kelley, M. E., Jones, D. A., Genemaras, A., Beckwith, J. G., Greenwald, R. M., Maerlender, A., et al. (2018) · Journal of Applied Biomechanics · doi:10.1123/jab.2017-0207 · Cited by 17
The relationship of migraine and other headache disorders to concussion
Seifert, T. (2018) · Handbook of clinical neurology · doi:10.1016/b978-0-444-63954-7.00012-4 · Cited by 17
The Role of Neck Musculature in Traumatic Brain Injuries in Older Adults: Implications From Sports Medicine
Wood, T. A., Morrison, S., & Sosnoff, J. J. (2019) · Frontiers in Medicine · doi:10.3389/fmed.2019.00053 · Cited by 17
“(11) reported that lower overall neck strength was a significant predictor of sportsrelated concussion.”
Background
174 Mechanisms of Injury as a Diagnostic Predictor of Sport-Related Concussion Severity in Football, Basketball, and Soccer
Zuckerman, S. L., Totten, D. J., Rubel, K. E., Kuhn, A. W., Yengo-Kahn, A. M., Solomon, G. S., & Sills, A. K. (2016) · Neurosurgery · doi:10.1227/01.neu.0000489743.00212.e6 · Cited by 17
Injury patterns in U15 rugby players in Ulster schools: A Rugby Injury Surveillance (RISUS) Study
Archbold, P. H. A., Rankin, A. T., Webb, M., Davies, R. J., Nicholas, R., Eames, N., Wilson, R. K., Vincent, J. E., McKeever, D., Duddy, K., et al. (2021) · Translational Sports Medicine · doi:10.1002/tsm2.248 · Cited by 16
Sex and posture dependence of neck muscle size-strength relationships
Reddy, C. P., Zhou, Y. M., Wan, B., & Zhang, X. (2021) · Journal of Biomechanics · doi:10.1016/j.jbiomech.2021.110660 · Cited by 16
Eight Weeks of Self-Resisted Neck Strength Training Improves Neck Strength in Age-Grade Rugby Union Players: A Pilot Randomized Controlled Trial
Attwood, M. J., Hudd, L.-J. W., Roberts, S., Irwin, G., & Stokes, K. (2021) · Sports Health A Multidisciplinary Approach · doi:10.1177/19417381211044736 · Cited by 16
“Higher neck strength has also been associated with reduced concussion in high school athletes.(6) The present study demonstrates that a 3-minute neck strength program taken from Activate offers an efficacious means for adolescent rugby players to improve their neck strength.”
Background
Covariation between formidability inferences and perceptions of men's preferred humor styles
Brown, M., Tracy, R. E., & Boykin, K. (2022) · Personality and Individual Differences · doi:10.1016/j.paid.2022.111792 · Cited by 15
Head Impact Locations in U.S. High School Boys' and Girls' Soccer Concussions, 2012/13–2015/16
Kerr, Z. Y., Campbell, K. R., Fraser, M. A., Currie, D. W., Pierpoint, L. A., Kaminski, T. W., & Mihalik, J. P. (2017) · Journal of Neurotrauma · doi:10.1089/neu.2017.5319 · Cited by 16
“31,32 Theories range from the biological (neck muscle strength differences) 33 to the sociocultural (concussion symptom disclosure differences).”
Evaluating the Effects of a Novel Neuromuscular Neck Training Device on Multiplanar Static and Dynamic Neck Strength: A Pilot Study
Versteegh, T., Dickey, J. P., Emery, C. A., Fischer, L. K., MacDermid, J. C., & Walton, D. M. (2019) · The Journal of Strength and Conditioning Research · doi:10.1519/jsc.0000000000003091 · Cited by 16
“(5) and was intended to facilitate interpretation of results for clinical and conditioning personnel and to determine if the training protocol could also be expected to improve strength across all planes when considered together.”
Background
Prevention strategies and modifiable risk factors for concussion: a systematic review and meta-analysis for the Female, woman and girl/or Athlete Injury pRevention (FAIR) consensus
Shill, I., Shepherd, H. A., Eliason, P., Kolstad, A. T., Heyward, O. W., Martens, G., Peek, K., Soligon, C. A., King, M., West, S. W., et al. (2025) · British Journal of Sports Medicine · doi:10.1136/bjsports-2025-109915 · Cited by 15
Biomechanics of Traumatic Head and Neck Injuries on Women: A State-of-the-Art Review and Future Directions
Carmo, G. P., Grigioni, J., Fernandes, F. A. O., & de Sousa, R. J. A. (2023) · Biology · doi:10.3390/biology12010083 · Cited by 16
“Studies have consistently shown that neck strength is higher in men than in women [106,107] and it has been demonstrated that neck strength declines with age [108,109].”
Background
Diffusion MRI as a complementary assessment to cognition, emotion, and motor dysfunction after sports-related concussion: a systematic review and critical appraisal of the literature
Hellewell, S. C., Welton, T., Pearce, A. J., Maller, J. J., & Grieve, S. M. (2020) · Brain Imaging and Behavior · doi:10.1007/s11682-020-00336-0 · Cited by 15
Characterization of cervical neuromuscular response to head-neck perturbation in active young adults
Alsalaheen, B. A., Bean, R., Almeida, A. A., Eckner, J. T., & Lorincz, M. (2018) · Journal of Electromyography and Kinesiology · doi:10.1016/j.jelekin.2018.01.011 · Cited by 15
Sex-Based Differences in Transcranial Doppler Ultrasound and Self-Reported Symptoms After Mild Traumatic Brain Injury
Thibeault, C. M., Thorpe, S., Canac, N., Wilk, S. J., & Hamilton, R. (2019) · Frontiers in Neurology · doi:10.3389/fneur.2019.00590 · Cited by 15
“Another consistent theme in mTBI gender differences is decreased neck strength in women (37, 38), which has been shown to be inversely related to concussion susceptibility.”
Background
The role of neck muscle co-contraction and postural changes in head kinematics after safe head impacts: Investigation of head/neck injury reduction
Homayounpour, M., Gomez, N. G., Vasavada, A. N., & Merryweather, A. (2021) · Journal of Biomechanics · doi:10.1016/j.jbiomech.2021.110732 · Cited by 14
Concussion in Female Athletes of Contact Sports: A Scoping Review
Fahr, J., Kraff, O., Deuschl, C., & Dodel, R. C. (2024) · Orthopaedic Journal of Sports Medicine · doi:10.1177/23259671241276447 · Cited by 15
“8 In soccer, women were found to exhibit significantly less neck strength when heading a ball than men.”
BackgroundInfluential
Estimating Concussion Incidence Using Sports Injury Surveillance Systems: Complexities and Potential Pitfalls.
Kerr, Z., Zuckerman, S., Register-Mihalik, J., Wasserman, E., McLeod, T. V., Dompier, T. P., Comstock, R., & Marshall, S. W. (2017) · Neurologic clinics · doi:10.1016/j.ncl.2017.03.001 · Cited by 16
Self-citation
Traumatic brain injury reduction in athletes by neck strengthening (TRAIN)
Toninato, J., Casey, H. L., Uppal, M., Abdallah, T., Bergman, T. A., Eckner, J. T., & Samadani, U. (2018) · Contemporary Clinical Trials Communications · doi:10.1016/j.conctc.2018.06.007 · Cited by 14

Authors: Collins, C. L., Fletcher, E. N., Fields, S. K., Kluchurosky, L., Rohrkemper, M. K., Comstock, R. D., & Cantu, R. C.
Affiliations: Nationwide Children's Hospital (US)
University of Colorado Denver (US)
Colorado School of Public Health (US)
Boston University (US)
Corresponding author: Comstock, R. Dawn
ORCID: Collins, Christy L.
Fletcher, Erica N.
Cantu, Robert C.
Venue: The Journal of Primary Prevention
Publisher: Springer Science and Business Media LLC
Published: 2014-06-15
Volume: 35
Issue: 5
Pages: 309-319
ISSN: 0278-095X (ISSN-L)
1573-6547
DOI: 10.1007/s10935-014-0355-2
OpenAlex: W2077683717
Cited by: 327
References: 31
Citations by year: 2026: 16 · 2025: 37 · 2024: 31 · 2023: 27 · 2022: 25 · 2021: 41 · 2020: 32 · 2019: 32 · 2018: 32 · 2017: 23 · 2016: 16 · 2015: 9 · 2014: 6
FWCI: 13.60
Type: journal article
Language: en
Open access: closed
Licence: www.springer.com/tdm (tdm)
Locations: The Journal of Primary Prevention (publishedVersion)
PubMed (publishedVersion)
Funders: National Operating Committee on Standards for Athletic Equipment
Centers for Disease Control and Prevention
Topics: Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports injuries and prevention
Physical Sciences › Engineering › Biomedical Engineering › Automotive and Human Injury Biomechanics
Keywords: neck muscle strength, sports-related concussion, high school athletes, hand-held dynamometry, anthropometry, neck circumference, athletic trainers, concussion screening, concussion prevention, soccer, basketball, lacrosse
MeSH terms: Adolescent, Adult, Age Factors, Anthropometry, Brain Concussion, Equipment Design, Feasibility Studies, Female, Humans, Male, Neck Muscles, Pilot Projects, Risk Factors, Sex Factors, Reproducibility of Results, Incidence, Muscle Strength, Muscle Strength Dynamometer

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

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