Head and Neck Characteristics as Risk Factors For and Protective Factors Against Mild Traumatic Brain Injury in Military and Sporting Populations: A Systematic Review

Nicholas J. Cooney, Paul Sowman, Nathan Schilaty, Nathaniel Bates, Timothy E. Hewett, Tim L.A. Doyle

Research output: Contribution to journalReview articlepeer-review


Background: Investigators have proposed that various physical head and neck characteristics, such as neck strength and head and neck size, are associated with protection from mild traumatic brain injury (mTBI/concussion). Objectives: To systematically review the literature and investigate potential relationships between physical head and neck characteristics and mTBI risk in athletic and military populations. Methods: A comprehensive search of seven databases was conducted: MEDLINE, EMBASE, CINAHL, Scopus, SPORTDiscus, Cochrane Library, and Web of Science. Potential studies were systematically screened and reviewed. Studies on military and athletic cohorts were included if they assessed the relationship between physical head-neck characteristics and mTBI risk or proxy risk measures such as head impact kinematics. Results: The systematic search yielded a total of 11,723 original records. From these, 22 studies met our inclusion criteria (10 longitudinal, 12 cross-sectional). Relevant to our PECO (Population, Exposure, Comparator, and Outcomes) question, exposures included mTBI incidence and head impact kinematics (acceleration, velocity, displacement) for impacts during sport play and training and in controlled laboratory conditions. Outcome characteristics included head and neck size (circumference, mass, length, ratios between these measures), neck strength and endurance, and rate of force development of neck muscles. Discussion: We found mixed evidence for head and neck characteristics acting as risk factors for and protective factors against mTBI and increased susceptibility to head impacts. Head-neck strength and size variables were at times associated with protection against mTBI incidence and reduced impact kinematics (14/22 studies found one or more head-neck variable to be associated with protection); however, some studies did not find these relationships (8/22 studies found no significant associations or relationships). Interestingly, two studies found stronger and larger athletes were more at risk of sustaining high impacts during sport. Strength and size metrics may have some predictive power, but impact mitigation seems to be influenced by many other variables, such as behaviour, sex, and impact anticipation. A meta-analysis could not be performed due to heterogeneity in study design and reporting. Conclusion: There is mixed evidence in the literature for the protective capacity of head and neck characteristics. We suggest field-based mTBI research in the future should include more dynamic anthropometric metrics, such as neck stiffness and response to perturbation. In addition, laboratory-based mTBI studies should aim to standardise design and reporting to help further uncover these complicated relationships.

Original languageEnglish (US)
Pages (from-to)2221-2245
Number of pages25
JournalSports Medicine
Issue number9
StatePublished - Sep 2022

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation


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