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

Isla J Shill; Heather A Shepherd; Paul H Eliason; Ash T Kolstad; Omar Heyward; Géraldine Martens; Kerry Peek; Clara A Soligon; Matthew G King; Stephen W West; Osman Hassan Ahmed; Cheri A Blauwet; Steven Broglio; Araba Chintoh; Jean-Michel Galarneau; K Alix Hayden; Sharief Hendricks; Michael Makdissi; Debbie Palmer; Stacy Sick; Jackie L Whittaker; Kay M Crossley; Kathryn J Schneider; Carolyn A Emery

doi:10.1136/bjsports-2025-109915

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

Br J Sports Med. 2025 Dec 3;59(22):1599-1616. doi: 10.1136/bjsports-2025-109915.

Authors

Isla J Shill^{1

2

3}, Heather A Shepherd⁴, Paul H Eliason², Ash T Kolstad², Omar Heyward^{5

6}, Géraldine Martens⁷, Kerry Peek^{8

9}, Clara A Soligon², Matthew G King¹⁰, Stephen W West^{2

11

12}, Osman Hassan Ahmed^{13

14

15}, Cheri A Blauwet¹⁶, Steven Broglio¹⁷, Araba Chintoh^{18

19}, Jean-Michel Galarneau², K Alix Hayden²⁰, Sharief Hendricks^{5

21}, Michael Makdissi^{22

23}, Debbie Palmer^{1

3}, Stacy Sick², Jackie L Whittaker^{24

25}, Kay M Crossley²³, Kathryn J Schneider², Carolyn A Emery²⁶

Affiliations

¹ Edinburgh Sports Medicine Research Centre, Institute for Sport, PE and Health Sciences, University of Edinburgh, Edinburgh, UK.
² Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.
³ UK Collaborating Centre on Injury and Illness Prevention in Sport, Universities of Edinburgh and Bath, Edinburgh and Bath, UK.
⁴ Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁵ Carnegie School of Sport, Leeds Beckett University, Leeds, UK.
⁶ Rugby Football Union, Twickenham, UK.
⁷ NeuroRecovery Lab, GIGA-Consciousness, University of Liège, Liège, Belgium.
⁸ FIFA Medical, Fédération Internationale de Football Association, Zurich, Switzerland.
⁹ Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
¹⁰ Discipline of Physiotherapy, La Trobe University, Bundoora, Victoria, Australia.
¹¹ UK Collaborating Centre on Injury and Illness Prevention in Sport, Universities of Edinburgh of Bath, Edinburgh and Bath, UK.
¹² Centre for Health, and Injury & Illness Prevention in Sport, University of Bath, Bath, UK.
¹³ The Football Association, Burton-upon-Trent, UK.
¹⁴ University Hospitals Dorset NHS Foundation Trust, Poole, UK.
¹⁵ School of Psychology, Sport and Health Sciences, University of Portsmouth, Portsmouth, UK.
¹⁶ Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, Massachusetts, USA.
¹⁷ University of Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA.
¹⁸ Dept. of Psychiatry, University of Calgary, Calgary, Alberta, Canada.
¹⁹ Centre for Sport Leadership, Maties Sport, Stellenbosch University, Stellenbosch, South Africa.
²⁰ Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada.
²¹ Division of Physiological Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
²² Australian Football League, Melbourne, Victoria, Australia.
²³ La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
²⁴ Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.
²⁵ Arthritis Research Canada, Vancouver, British Columbia, Canada.
²⁶ Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada caemery@ucalgary.ca.

Abstract

Objective: To examine prevention strategies and potential modifiable risk factors (MRFs) for sport-related concussion (SRC) and head impact/head acceleration event (HAE) outcomes in female, woman and/or girl athletes.

Design: Systematic review with meta-analyses and Grading of Recommendations, Assessment, Development and Evaluation.

Data sources: Medline, CINAHL, PsycINfo, SportDiscus, ERIC, CENTRAL and CDSR.

Eligibility: Primary data studies with comparison group(s) assessing the association of prevention interventions and/or MRFs for SRC or HAE with ≥1 female/woman/girl in each study group.

Results: Of the 108 included studies, 67 evaluated a SRC prevention strategy (equipment n=25, policy/rule n=21, training n=10, management n=11) and 41 evaluated potential MRFs (34 distinct MRFs across nine categories). In total, 40/108 (37%) studies (prevention 19/67; MRF 21/41) included female/woman/girl-specific estimates. Three meta-analyses were conducted: two SRC prevention strategies (headgear, eyewear) and one MRF (artificial turf vs grass) based on availability of female/woman/girl-only estimates and similar outcomes and exposure. Headgear was associated with 30% lower SRC rates in adolescent female/girl lacrosse and soccer (IRR=0.70, 95% CI 0.50 to 0.99; very-low certainty). Eyewear use was not protective for SRC (IRR=1.08, 95% CI 0.69 to 1.68; very-low certainty). SRC rates did not differ by artificial turf versus grass (IRR=0.95, 95% CI 0.62 to 1.45; very-low certainty).

Conclusion: We found limited evidence for prevention strategies and MRFs in female/woman/girl athletes except for very-low certainty evidence supporting headgear use in adolescent lacrosse and soccer. Future studies should consider the design, implementation and evaluation of SRC prevention strategies that target MRFs to guide safe practice recommendations specifically for female/woman/girl athletes.

Keywords: Brain Concussion; Female; Risk factor; Women in sport.

Publication types

Systematic Review
Meta-Analysis

MeSH terms

Athletic Injuries* / prevention & control
Brain Concussion* / prevention & control
Consensus Statements as Topic
Female
Head Protective Devices
Humans
Risk Factors