In Reply Thank you for your letters and interest in our study. We appreciate concerns that our concussion incidence rate was inflated but we believe it represents the best estimate in our study population. We currently lack an objective tool to confirm or rule out concussion; symptom checklists are a primary means by which concussion is diagnosed.1 While it is true that these symptoms are short-lived in many of our participants, the current clinical definition of concussion2 does not stipulate symptoms must be present for a minimum amount of time. In several studies, the primary finding has been that a significant proportion of athletes do not report their symptoms.3,4 Clearly, the greater the reporting burden on the athlete and the greater the amount of time between the injury and the assessment of symptoms, the lower the concussion incidence rate. Whether or not transient neurocognitive symptoms that resolve quickly are of relevance is an unanswered question, but the consensus is that we would like all athletes to report their symptoms. For clarification, our Internet injury-surveillance system did not involve reporting by coaches or medical professionals but only the participants reporting via their parents. We appreciate the observation that if we considered only the medically diagnosed concussions our incidence rates would be similar to other studies. This is exactly our point, that many athletes do not report concussion symptoms to their coaches or athletic trainers, and as a result, the incidence rates in the literature that rely on athlete reporting is artificially low. We also suspect other physicians, physician assistants, and athletic trainers misdiagnosed concussions in our study, highlighting the need for additional training in recognizing and reporting concussions. Our participants who saw a physician, physician assistant, or athletic trainer but did not receive a concussion diagnosis had an average of 3.5 concussion symptoms and had symptoms lasting an average of 7.5 days.
O’Kane JW, Schiff MA. Concerns About Concussion Rates in Female Youth Soccer—Reply. JAMA Pediatr. 2014;168(10):968. doi:10.1001/jamapediatrics.2014.780