702938

research-article2017
CPJXXX10.1177/0009922817702938Clinical PediatricsNaiyer et al

Article
Clinical Pediatrics

Pediatric Cheerleading Injuries Treated 2017, Vol. 56(11) 985­–992

© The Author(s) 2017
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DOI: 10.1177/0009922817702938
https://doi.org/10.1177/0009922817702938

United States journals.sagepub.com/home/cpj

Nada Naiyer, BS1, Thiphalak Chounthirath, MS1,

and Gary A. Smith, MD, DrPH1,2,3

Abstract
This study investigates the epidemiology of cheerleading injuries to children in the United States. Data were
analyzed from the National Electronic Injury Surveillance System for children 5 through 18 years of age treated
in US emergency departments for cheerleading injuries from 1990 through 2012. An estimated 497 095 children
ages 5 to 18 years were treated in US emergency departments for a cheerleading injury during the 23-year study
period, averaging 21 613 injured children per year. From 1990 to 2012, the annual cheerleading injury rate increased
significantly by 189.1%; and from 2001 to 2012, the annual rate of cheerleading-related concussion/closed head
injury increased significantly by 290.9%. Falls were the most common mechanism of injury (29.4%) and were more
likely to lead to hospitalization (relative risk = 2.47; 95% confidence interval = 1.67-3.68) compared with other injury
mechanisms. The rising number and rate of pediatric cheerleading injuries underscore the need for increased efforts
to prevent these injuries.

Keywords
National Electronic Injury Surveillance System, sports, trauma, injury, children

Introduction Cheerleading Reporting Information Online surveil-

Cheerleading was first introduced in 1898, and by the
1960s, it had spread to nearly all high schools, grade
schools, and recreational leagues.1 Cheerleading partici-
pation (including recreational, school, collegiate, and
all-star cheerleaders) continues to increase, from 3.03
million in 1990 to 4.15 million in 2005.2 In 2009, the
National Federation of State High Schools Association
(NFHS) estimated there are approximately 400 000 high
school cheerleaders in the United States.3 Over the
years, cheerleading has evolved from jumps, splits, and
clasps to incorporating advanced gymnastic skills, such
as tumbling and stunts, including pyramids and tosses.1
As participation in cheerleading has increased and
maneuvers become more complex, the number of inju-
ries has increased.4 In 2007, there were almost 26 800
cheerleading injuries treated in US emergency depart-
ments (EDs).5 Not only are cheerleading injuries com-
mon, they also can be serious. According to the National
Center for Catastrophic Sport Injury Research, high
school cheerleaders accounted for about two thirds of all
female high school catastrophic sports injuries.6
Previous studies have described the injuries and risks
associated with cheerleading.4-13 Publications from the
lance study were based on a national convenience sam-
ple over a 1-year period.9-13 Two studies utilized the
nationally representative National Electronic Injury
Surveillance System (NEISS) to describe the epidemiol-
ogy of cheerleading injuries; one focused on the pediat-
ric population,4 while the other covered all age groups.8
A more recent study examined injuries to high school
cheerleaders.14 In 2012, the American Academy of
Pediatrics (AAP) released a policy statement regarding
cheerleading injuries and provided 12 recommendations
for injury prevention.5
This study investigates pediatric cheerleading inju-
ries using a nationally representative database from
1
Center for Injury Research and Policy, The Research Institute at
Nationwide Children’s Hospital, Columbus, OH, USA
2
The Ohio State University College of Medicine, Columbus, OH,
USA
3
Child Injury Prevention Alliance, Columbus, OH, USA
Corresponding Author:
Gary A. Smith, Center for Injury Research and Policy, The Research
Institute at Nationwide Children’s Hospital, 700 Children’s Drive,
Columbus, OH 43205, USA.
Email: gary.smith@nationwidechildrens.org
986 Clinical Pediatrics 56(11)
1990 through 2012. It covers a longer time period than
previous studies and assesses whether there have been
changes in the frequency or patterns of injury as aware-
ness of cheerleading safety has increased, especially
during the past decade.
Methods
Data Sources
Data were obtained from the NEISS for children 5
through 18 years, who were treated in hospital EDs for a
cheerleading injury from January 1, 1990, through
December 31, 2012. The US Consumer Product Safety
Commission (CPSC) maintains the NEISS, which col-
lects data from a stratified probability sample of approx-
imately 100 EDs from among the more than 5300
hospital EDs providing 24-hour care with at least 6 beds
in the United States and its territories.15 NEISS coders
from participating hospitals enter data into the NEISS
database from patient ED medical records, including
injured patients’ age, gender, injury diagnosis, injured
body region, locale of injury, and a short narrative
describing the circumstances of the injury event.
Cheerleading injuries were identified using the
NEISS code 3254 for cheerleading. Each case narrative
was reviewed for potential miscoding and to ensure it
met inclusion criteria. A case was excluded from the
study if its narrative mentioned “drill team,” “color
guard,” “flag corps,” or “flag line,” or if the injury
occurred before or after the cheerleading activity. There
were 13 242 cases included in this study. US Census
Bureau July 1 intercensal and postcensal population
estimates for US residents ages 5 to 18 were used as the
denominator for injury rate calculations.16-18
Variables
NEISS injury diagnoses were categorized into (1) strain/
sprain, (2) soft tissue injury (including hematoma, crush
injury, contusion, and abrasion), (3) fracture, (4) dislo-
cation, (5) laceration (including punctures and avul-
sions), (6) concussion/closed head injury (CHI;
including internal injury to the head), and (7) other.
NEISS body regions were grouped into (1) upper
extremity (including shoulder, upper and lower arm,
elbow, wrist, hand, and finger), (2) lower extremity
(including upper and lower leg, knee, ankle, foot, and
toe), (3) head/neck (including head, ear, eye, face,
mouth, and neck), (4) trunk (including upper and lower
trunk and pubic region), and (5) other (including non-
head internal injury and injury to ≥25% of body). Locale
of injury was grouped into (1) home (including home
and apartment/condo), (2) school, (3) sports/recreational
place, and (4) other (including street/highway, other
public property, and industrial place). Disposition from
the ED was categorized into (1) treated and released (or
examined and released without treatment), (2) hospital-
ized (including treated and transferred to another hospi-
tal, treated and transferred for hospitalization, treated
and admitted for hospitalization within same facility,
and held for <24 hours in an observation unit), and (3)
left against medical advice.
Information from the NEISS case narratives was
used to code variables for the mechanism of injury,
maneuver being attempted at the time of injury, and type
of cheerleading activity during which the injury
occurred. The mechanism of injury was grouped into (1)
struck (including struck by object and excluding struck
by another person), (2) collision (including 2 or more
people, collision between cheerleaders, struck another
cheerleader, or struck by another cheerleader), (3) fall,
(4) overuse, (5) twisted, (6) wrong landing, (7) dropped,
and (8) other. The maneuver being attempted at the time
of injury was classified as (1) stunt, (2) tumbling, (3)
cheerleading, not otherwise specified (NOS), and (4)
other (including running, dancing, and other activities).
Stunts are defined as “one or more persons supporting
one or more top persons off of the ground,” including
bases, top persons, and pyramids.19 Tumbling consists
of individual gymnastic-type maneuvers, including cart-
wheels, round-offs, handsprings, tucks, and hand-
stands.19 Case narratives that indicated “cheerleading”
as the cause of injury were categorized as “cheerleading,
NOS,” and narratives indicating maneuvers other than
stunts, tumbling, or general cheerleading as the cause of
injury were categorized as “other” maneuvers. The type
of cheerleading event where an injury occurred was cat-
egorized into (1) practice, (2) game, (3) competition, (4)
try-out, (5) camp, and (6) not specified. Age groups
were categorized into younger children (ages 5-11 years)
and older children (ages 12-18 years) in order to com-
pare injuries during the elementary school years and the
middle/high school years.
Data Analysis and Ethical Considerations
Data were analyzed using IBM SPSS Statistics for
Windows Version 21.0 (IBM Corp, Armonk, NY) and
SAS Version 9.3 (SAS Institute, Inc, Cary, NC) statisti-
cal software. Sample weights provided by the CPSC
were used to calculate national estimates for cheerlead-
ing injuries. All estimates reported are stable estimates
unless stated otherwise. An estimate is considered
potentially unstable if the estimated frequency is <1
200, the actual sample size is <20, or the coefficient of
Naiyer et al 987
Figure 1.  Estimated number of children ages 5 to 18
years treated for cheerleading injuries in US emergency
departments by age, 1990 to 2012.
variation exceeds 30%. Statistical analyses included lin-
ear regression, Rao-Scott’s χ2 test, and calculation of
relative risks (RRs) with 95% confidence intervals
(CIs). Linear regression was used to analyze secular
trends in the number and rate of cheerleading injuries.
The estimated slope from the regression model (m) is
reported with the associated P value. Statistical signifi-
cance was determined at α = .05. The institutional review
board of the authors’ institution judged this study to be
exempt.
Results
Demographic Characteristics and Injury
Trends
An estimated 497 095 (95% CI = 384 386-609 804) chil-
dren 5 to 18 years old were treated for cheerleading inju-
ries in US EDs from 1990 to 2012, averaging 21 613
(95% CI = 16 712-26 513) children per year. The aver-
age age of injured participants was 14.1 years (SD =
0.07; median 14.0, interquartile range = 12.2-15.5), with
86.4% of patients being 12 to 18 years old (Figure 1).
Patients ages 12 to 18 years had an injury rate that was
6.3 times higher than that of patients 5 to 11 years old
(66.7 compared with 10.6 injuries per 100 000 children,
respectively). Most of the injured cheerleaders were
female (97.6%), and 79.5% of the injuries occurred dur-
ing the months of August through February.
Over the 23-year study period, the annual number of
cheerleading injuries increased significantly by 242.8%
(m = 1158.8, P < .001), from 10 895 (95% CI = 6917-
14 873) in 1990 to 37 344 (95% CI = 23 750-50 938) in
2012 (Figure 2). This corresponds to a significant
189.1% increase (m = 1.82, P < .001) in the annual
injury rate per 100 000 children, from 22.3 (95% CI =
14.1-30.4) in 1990 to 64.3 (95% CI = 40.9-87.7) in
Figure 2.  Estimated annual number and rate of children
ages 5 to 18 years treated for cheerleading injuries in US
emergency departments, 1990 to 2012.
Figure 3.  Estimated annual number and rate of children
ages 5 to 18 years treated for cheerleading-related
concussions/closed head injuries in US emergency
departments, 1990 to 2012.
2012. Stable estimates for the annual concussion/CHI
frequencies and rates were available for 2001 to 2012.
During this period, the annual frequency of concussion/
CHI increased significantly by 294.9% (m = 356.4, P <
.001) from 1476 (95% CI = 905-2048) in 2001 to 5829
(95% CI = 2987-8670) in 2012, and the concussion/CHI
rate per 100 000 children increased by 290.9% (m =
0.61, P < .001) from 2.6 (95% CI = 1.6-3.6) in 2001 to
10.0 (95% CI = 5.1-14.9) in 2012 (Figure 3).
Body Region Injured
Injuries to the lower (32.9%) and upper (31.6%) extrem-
ities accounted for the majority of cheerleading injuries,
followed by the head/neck (22.8%) and trunk (11.9%)
(Table 1). Joint injuries (including ankle, knee, wrist,
and elbow) were common, accounting for 39.4% of all
cheerleading injuries (16.0% ankle, 9.2% knee, 9.2%
wrist, and 5.0% elbow). The knee and ankle accounted
for 76.9%% of lower extremity injuries, while the elbow
988 Clinical Pediatrics 56(11)
and wrist accounted for 44.9% of upper extremity
injuries.
Lower extremity injuries (33.6%) were more com-
mon among patients ages 12 to 18 years, while upper
extremity injuries (42.7%) were more common among
younger patients ages 5 to 11 years. Patients ages 5 to 11
years were 1.43 (95% CI = 1.29-1.60) times more likely
to injure the upper extremities than patients 12 to 18
years old.
Injury Diagnosis
Strains/sprains accounted for 47.7% of cheerleading inju-
ries, followed by soft tissue injuries (16.8%) and fractures
(14.1%; Table 1). Upper extremity injuries were more
likely (RR = 3.23; 95% CI = 2.92-3.59) to be diagnosed
as fractures than injuries to other body regions. Younger
patients were 1.91 (95% CI = 1.69-2.15) times more
likely to sustain a fracture than older patients.
Locale and Type of Event
Among the 79.3% of cases where locale of the injury was
reported, the majority (56.7%) occurred at school, fol-
lowed by sports/recreational place (37.7%), home (3.6%),
and other place (2.0%). Patients ages 5 to 11 years were
most often injured at a sports/recreational place (48.4%),
while most older patients were injured at school (58.8%).
The type of cheerleading event where the injury
occurred was documented in 36.2% of cases; of which,
79.7% occurred during practice, 8.2% during a game,
6.6% at camp, 3.7% at competition, and 1.8% at try-outs.
Mechanism of Injury and Cheerleading
Maneuver
The most common mechanism of injury was a fall
(29.4%), followed by overuse (23.8%) and collision
(13.7%; Table 1). Compared with other mechanisms of
injury, a collision (RR = 3.58; 95% CI = 3.32-3.88) was
more likely to result in an injury to the head/neck region,
and getting dropped (RR = 3.53; 95% CI = 2.74-4.56)
was more likely to result in a concussion/CHI.
Cheerleading maneuvers NOS accounted for 73.6%
of the cheerleading injuries in this study, followed by
stunts (14.6%) and tumbling (10.7%). Stunts were more
likely (RR = 2.39; 95% CI = 2.07-2.78) to result in a
concussion/CHI than other maneuvers.
Disposition From the ED
Most (98.4%) patients with a cheerleading injury were
treated and released, while 1.2% were hospitalized
(Table 1). Of those hospitalized, 46.1% were diagnosed
with a fracture and 22.4% were diagnosed with a con-
cussion/CHI. Patients with a fracture were more likely
to be admitted to the hospital than patients with other
injury diagnoses (RR = 5.20; 95% CI = 3.22-8.42).
Additionally, when compared with other mechanisms of
injury, a fall was more likely to result in hospitalization
(RR = 2.47; 95% CI = 1.67-3.68).
Discussion
From 1990 to 2012, there were 497 095 children 5 to 18
years old with a cheerleading injury treated in US EDs,
averaging 21 613 children annually. The number of
injured children increased significantly by 242.8%
between 1990 and 2012, more than doubling the 110%
increase previously reported for the period of 1990 to
2002.4 The increase in the frequency of injuries is most
likely due to the increase in the number of cheerleading
participants, which increased from 3.03 million in 1990
to 4.15 million in 2005,2 and the increase in the athleti-
cism of the activity. Since 1960, cheerleading has
evolved from short jumps and pompom shaking to the
present-day higher risk activity involving complex gym-
nastic maneuvers.6 Although cheerleading is a year-
round activity, the majority (79.6%) of injuries occurred
between August and February, which corresponds to
football (September to November) and basketball
(December to February) seasons.
The number and rate of cheerleading-related concus-
sions/CHIs increased significantly by more than 200%
from 2001 to 2012. This increase may reflect a true
increase in the incidence of these injuries. However, it
also could be influenced by changes in diagnosis deci-
sion making or documentation in medical records by
health care providers or by changes in care-seeking
behaviors by parents, which may have been influenced
by the growing public awareness about sports-related
concussions and traumatic brain injury. The recent pas-
sage of state laws addressing youth sports-related con-
cussions demonstrates this heightened attention.20-22
The most common type of cheerleading injury was
strain/sprain (47.7%), which is consistent with other
studies on cheerleading injuries4,8,13 and other sports.23-29
Strain/sprain injuries occur more often to the lower
extremities than the upper extremities. However, for
younger children, upper extremity injuries were more
common (42.7%), which also agrees with other stud-
ies.4,27,29-32 To prevent strain/sprain injuries, it is impor-
tant to know proper lifting and falling techniques.
Conditioning and training exercises, including resis-
tance exercises and stretching, may help prevent some
injuries.5,33 Injuries are often associated with fliers
Naiyer et al 989

Table 1.  Characteristics of Cheerleading Injuries Among Children Ages 5 to 18 Years Treated in US Emergency
Departments, 1990 to 2012.

Characteristics Number of Cases National Estimate (%)a 95% CI

Study total 13 242 497 095 (100.0) 384 959-609 231

Age (years)
 5-11 2028 67 467 (13.6) 49 102-85 832
 12-18 11 214 429 628 (86.4) 334 446-524 810
 Subtotal 13 242 497 095 (100.0) 384 959-609 231
Gender
 Male 330 12 066 (2.4) 9039-15 094
 Female 12 912 485 029 (97.6) 375 478-594 579
 Subtotal 13 242 497 095 (100.0) 384 959-609 231
Diagnosis
 Sprain/strain 6024 237 035 (47.7) 187 841-286 230
  Soft tissue injury 2090 83 399 (16.8) 64 820-101 978
 Fracture 1950 70 082 (14.1) 51 419-88 746
 Concussion/CHI 1125 35 079 (7.1) 24 638-45 520
 Laceration 440 16 118 (3.2) 12 290-19 945
 Dislocation 260 9694 (2.0) 6933-12 456
 Other 1340 45 190 (9.1) 24 179-66 201
 Subtotal 13 229 496 598 (100.0) 384 579-608 617
Body region injured
  Lower extremity 4198 163 167 (32.9) 127 595-198 738
  Upper extremity 4025 156 641 (31.6) 118 484-194 799
 Head/neck 3273 113 317 (22.8) 85 880-140 754
 Trunk 1560 58 845 (11.9) 45 796-71 894
 Other 160 4441 (0.9) 2772-6110
 Subtotal 13 216 496 411 (100.0) 384 345-608 478
Disposition from ED
  Treated and released 12 946 489 279 (98.5) 378 411-600 147
 Admitted 252 6181 (1.2) 4502-7859
  Left against medical advice 40 1512 (0.3)b 578-2447
 Subtotal 13 238 496 972 (100.0) 384 862-609 081
Mechanism of Injury
 Fall 3971 145 947 (29.4) 113 184-178 709
 Overuse 3069 118 388 (23.8) 91 998-144 779
 Collision 1788 67 983 (13.7) 49 953-86 012
 Twisted 764 31 297 (6.3) 23 114-39 480
 Struck 320 12 940 (2.6) 8999-16 881
 Dropped 264 10 222 (2.1) 7443-13 002
  Wrong landing 234 9144 (1.8) 5905-12 383
 Other 247 6867 (1.4) 4580-9153
 Unspecified 2585 94 307 (19.0) 68 365-120 250
 Subtotal 13 242 497 095 (100.0) 384 959-609 231
Type of maneuver
  Cheerleading, NOS 9671 365 926 (73.6) 280 139-451 714
 Stunt 1973 72 640 (14.6) 55 665-89 615
 Tumbling 1480 54 235 (10.9) 40 715-67 754
 Other 118 4294 (0.9) 3050-5538
 Subtotal 13 242 497 095 (100.0) 384 959-609 231

Abbreviations: CI, confidence interval; CHI, closed head injury; ED, emergency department; NOS, not otherwise specified.
a
Percentages may not sum to 100.0% due to rounding error.
b
Estimate is potentially unstable because coefficient of variation exceeds 30%.
990 Clinical Pediatrics 56(11)
(cheerleaders thrown into the air), but spotters (cheer-
leaders responsible for assisting and catching the top
person in a partner stunt or pyramid) and base positions
(cheerleaders on the bottom of a partner stunt or pyra-
mid) are also at risk of injury. In fact, concussions are
more common among spotters and bases.13 Spotters and
bases need adequate upper body and core strength as
well as balance to support flyers. Cheerleaders serving
as spotters should be trained in proper spotting
techniques.5
Studies of other sports have shown that injury rates
are higher during competition than in practice.34
However, in this study, cheerleading injuries occurred
most commonly during practice, followed by game,
camp, and competition, which is similar to previous
cheerleading studies.8,35 This is likely due to the propor-
tionately greater amount of time cheerleaders spend in
practice than in other types of events, and because cheer-
leaders may still be developing their skills during prac-
tice. In cheerleading, the types of maneuvers performed
during competitions and games are the same as those
performed during practices.
The leading mechanism of injury was falls (29.4%),
which is consistent with other studies,6,30,34 and falls
were more likely to lead to hospitalization than other
mechanisms of injury in this study. Previous studies
have found that fall-related injuries are more often
caused by stunts than tumbling,10,36 and that partner
stunts and pyramids have the highest risk of injury.36
Several stunts and tumbling maneuvers, such as basket
tosses (where 3 or more bases toss a flier) and twisting
tumbling skills, are restricted to performance over more
cushioning surfaces, such as mat, grass, or rubberized
track surfaces, according to the School Cheer Safety
Rules of the American Association of Cheerleading
Coaches and Administrators (AACCA).19 However,
these rules are still not strict enough based on a study of
critical fall heights for typical surfaces on which cheer-
leaders perform.11 It is important that cheerleaders,
coaches, and parents be aware of both the surface on
which the cheerleading activity is conducted and the
height that is being reached during stunts. These are the
2 main factors that determine the amount of energy
transferred to a cheerleader’s body during impact from a
fall.
The AAP recommends that pyramids and partner
stunts only be performed on a spring floor or with a
landing mat on either a traditional foam floor or grass/
turf, and that no cheer activities occur on dirt, vinyl
floors, concrete, or asphalt.5 A number of maneuvers are
now restricted or prohibited due to safety concerns. For
example, the AAP recommends that rules for high
school cheerleading should restrict pyramid heights to 2
body lengths.5,33 Beginning with the 2010-2011 season,
all basket tosses and double full twisting dismounts
were prohibited by the AACCA on all surfaces for ele-
mentary, middle, and junior high school teams.30 Starting
with the 2012-2013 season, a double twist to a cradle is
not permitted in high school cheerleading according to
NFHS.37 However, these restrictions need to be strength-
ened. For example, the height of 2 body lengths may still
be too high depending on the energy-absorbing capacity
of the surface, and it is unclear whose body length is
being used. Even though the AAP considers grass as an
appropriate surface for cheerleading, it is not considered
an appropriate surface under playground equipment
because of its variable and inadequate cushioning capac-
ity.38 Thus, current recommendations, which are primar-
ily consensus-driven, need to be strengthened based on
evidence, especially given the increasing numbers and
rates of cheerleading injuries observed in this study.
During recent years, cheerleading safety rules and
recommendations have been adopted and updated by the
AACCA19 and NFHS.39 In addition, CheerSafe was
launched in March 2013, which is a coalition of organi-
zations concerned about cheerleading safety, including
the NFHS, National Collegiate Athletic Association,
International Cheer Union, National Athletic Trainers’
Association, and University Risk Managers and Insurers
Association. The 3-prong approach to safety promoted
by CheerSafe includes a knowledgeable coach, safety
rules, and an emergency plan.40
Although the AAP recommended that cheerleading
be designated as a sport in 2012, a recommendation
echoed by the American Medical Association in 2014, it
is still not universally considered a sport by all state high
school athletic associations, nor by the NFHS and
National Collegiate Athletic Association.5,41 The desig-
nation as a sport would provide cheerleading with the
same benefits as other sports, including access to certi-
fied coaches, athletic trainers, better facilities, and other
resources, as well as inclusion in injury surveillance sys-
tems.5 Some states have passed laws to address this
issue. For example, in 2012, New Jersey enacted a law
providing cheerleaders with the same level of protection
as other athletes. Cheerleaders are now included in the
student-athlete head injury safety training program. The
legislation also specified training for coaches.42,43
Additional recommendations to reduce cheerleading
injuries include safety training and certification for
coaches, completion of preparticipation physical exami-
nations for cheerleaders, availability of athletic trainers,
and improved national surveillance of cheerleading inju-
ries across age groups and types of cheer affiliations. With
better data, including mechanism of injury, maneuver
attempted at the time of injury, fall height, and surface
impacted, more specific and evidence-based strategies
could be developed, implemented, and evaluated.
Naiyer et al 991
Study Limitations
This study has several limitations. The NEISS database
does not capture cheerleading injuries treated in non-ED
settings. Therefore, this study underestimates the actual
number of cheerleading injuries, and the injuries
reported in this study may not be representative of the
entire spectrum of cheerleading injuries. In addition,
cheerleading participation data were not available;
therefore, population data were used to calculate injury
rates. Finally, NEISS case narratives vary in detail and
completeness, which limited our ability to evaluate
additional variables, such as maneuver attempted, type
of event at which the injury occurred, mechanism of
injury, height of fall, and impact surface.
Conclusions
The number and rate of pediatric cheerleading injuries
continue to rise, which underscores the need for increased
efforts to prevent these injuries. Emphasis should be
placed on widespread adoption of and compliance with
national safety rules, safety training for coaches and par-
ticipants, and improved cheerleading injury surveillance
and reporting. In addition, current rules need to be
strengthened, and more research is needed to further
develop the evidence for these rules. Cheerleading should
be designated as a sport and be provided with resources
and benefits comparable with other sports.
Author Contributions
NN conducted the data analysis, drafted and revised the manu-
script, and approved the final manuscript. TC assisted in data
analysis, revised the manuscript, and approved the final manu-
script. GAS conceptualized the study, assisted in data analysis,
critically reviewed and revised the manuscript, and approved
the final manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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