Sport-related injuries are exceedingly common in adolescent athletes, with estimates of injury prevalence ranging from 34% to 65% [1]. Contact sports, such as soccer, basketball, and football, confer especially high injury risk [1-3], with lower-extremity orthopedic injuries and concussions among the most common injuries sustained by athletes [4]. These injuries can lead to missed practices and competitions, absenteeism from school and associated learning losses, decreased quality of life, and mental health consequences [5-7]. Therefore, preventing injury among youth athletes is pivotal.

To date, numerous strategies have been implemented to reduce sport-related injury risk in youth sports. These include personal protective equipment, such as mouth guards and eyewear in hockey, rule changes (eg, banning cross-checking in ice hockey, reducing collision practices in football, and limiting pitch counts in baseball), tailored training strategies, including neuromuscular training warm-ups and resistance training, and reducing sport specialization by promoting multisport participation [8-11]. However, it is also important to consider interventions that bolster intrinsic, individual factors to build resilience and reduce the risk of sport-related injuries.

Visual processing efficiency—the speed and accuracy with which an individual can perceive and process visual stimuli—represents a promising target for intervention, as various visual cognitive abilities have been implicated in sport performance and injury risk. For instance, better visual attention skills are associated with lower-extremity musculoskeletal injury risk in adolescent athletes [12]. Faster visual reaction times allow players to better see the game around them and make faster decisions [13]. Furthermore, strong visual attention abilities are thought to help athletes anticipate collisions on the field and reduce sport-related injuries, including concussions, with peripheral vision playing a key role in the processing of multiple visual stimuli simultaneously [14]. Therefore, weaker visual processing skills may make athletes more vulnerable to on-field collisions and injuries [14]. Crucially, visual processing efficiency is modifiable through cognitive training [15-20], and improving youth athletes’ visual abilities may reduce sport-related injury risk.

The useful field of view (UFOV) cognitive training program has been studied extensively in adults and has been shown to reliably improve visual processing efficiency [15-20]. UFOV training focuses on improving visual processing speed and strengthening rapid visual detection of stimuli amid irrelevant visual clutter in the center and at the periphery of the visual field [21]. Importantly, improvements in visual processing efficiency gained through UFOV training have been shown to transfer to real-world improvements in functional outcomes, such as activities of daily living in older adults [17,22-25]. Enhanced visual and cognitive performance from UFOV training also improves older adults’ driving performance and safety [17,26-29]. Critically, improvements in visual processing efficiency have been shown to persist for periods ranging from 2 to 10 years, indicating that UFOV cognitive training can have lasting impacts on visual processing and real-life skills [17,19,25-30].

Given the benefits of UFOV cognitive training on visual processing in older adults and the importance of visual processing efficiency in reducing sport-related injury risk in youth, we hypothesize that UFOV training could benefit adolescent athletes at high risk for concussion and musculoskeletal injuries. Notably, visual processing skills improve throughout childhood and begin to reach adult levels in adolescence [31]. Therefore, this developmental period is ideal for interventions aiming to improve visual processing efficiency with long-lasting impacts. Developmentally, adolescence represents a period of ongoing maturation and neuroplasticity in frontoparietal attentional networks, suggesting potential responsiveness to targeted cognitive training interventions [32-34]. This pilot study is the first to examine UFOV cognitive training in youth. Here, we preliminarily assess the feasibility and acceptability of a 5-week UFOV training program in adolescent athletes and report on the magnitude of change in visual processing efficiency from pre- to posttraining as a foundation for future trials designed to evaluate efficacy.

Preliminary evidence shows that a 5-week UFOV training program is feasible for adolescents with the coaching support and compensation provided in this research setting. This training program can be completed at home or elsewhere and is commercially available, with strong potential for scalability. Although compensating adolescents for engaging in training may not be feasible at scale, we expect that once efficacy is better established, anticipated gains and program benefits will be enough incentive for engagement. Additionally, prior work has demonstrated the value of incorporating a training coach as part of remote cognitive training programs [41,42], which we expect was helpful in supporting engagement and adherence in this pilot study. Training coaches worked with participants to establish personalized training schedules, which gave participants flexibility and allowed them to optimally schedule their training amid other engagements (full-time jobs or internships, school, club sports, or other extracurriculars) while maintaining the fidelity of the program and receiving the target dosage. Of note, we deliberately enrolled participants during the summer months, as we expected that training would be most feasible for youth athletes during months when school was not in session. However, 3 participants started school toward the end of the training program, with 2 of the 3 still maintaining strong adherence during this time. Future work is needed to determine if this training program would be optimally deployed during a specific time of year or if the intervention or coaching sessions should ideally be delivered in an individual versus group setting [43].

Our early findings also suggest a high degree of intervention acceptability. On average, participants indicated positive views toward the program in terms of how enjoyable and easy to use it was, that it seemed beneficial, and that they would use the program outside of the study or recommend it to others. Though meaningful, these results are limited to participant responses to a survey, which are subject to bias and may not reflect participants’ true views of the intervention. Future work incorporating qualitative approaches may also be informative and could shed light on further opportunities to enhance acceptance of the intervention.

We observed improvement in visual processing efficiency from pre- to posttraining in this initial proof-of-concept study. The presence of posttraining ceiling scores suggests potential measurement constraints of the Double Decision Assessment in high-performing adolescents, which may limit sensitivity to additional gains. Future randomized trials should evaluate whether the skills adolescents gain from training result in enhanced performance on vision-dependent tasks and transfer to untrained tasks and real-world safety outcomes. Given the critical role of visual processing in sport performance, on-field reaction time, and collision avoidance, we theorize that improving visual processing with UFOV training may reduce sport-related injuries among adolescent athletes. However, it remains unknown whether improvements in computerized threshold-based tasks translate to complex, dynamic sport environments that require anticipation, motor coordination, and multisensory integration. Data on the longevity of skill transfer in adults suggests that if efficacious, benefits may persist throughout the sports season and beyond [17,19,25-30]. Mounting evidence has demonstrated that adolescent athletes with a history of concussion are at increased risk for sustaining repeat concussions or new musculoskeletal injuries, even after they are considered fully recovered by medical providers [44-47]. The current study included 2 adolescents with a prior history of concussion who were able to complete the intervention; future studies designed to evaluate the efficacy of UFOV training may consider enrolling adolescent athletes who are returning to sport after concussion and are therefore at heightened risk for repeat injuries.

The current study represents an important first step in evaluating UFOV training as a feasible tool to enhance visual processing in adolescents. However, the authors acknowledge that this preliminary study was significantly limited in terms of its small sample size and associated threats to generalizability. While we were able to quantify pre-post change in visual processing efficiency, a follow-up randomized controlled trial will be needed to evaluate the efficacy of UFOV, ideally relative to an active control intervention.

To our knowledge, this is the first study to implement and report on UFOV cognitive training in adolescents. Our preliminary results demonstrate that it is feasible to utilize this intervention in adolescents and not only in adult populations. However, the supports included in this study do not reflect real-world use, and future work will be needed to evaluate feasibility in larger studies and in other contexts (eg, team-based environments with additional structure but without support or compensation from the research team). Future work investigating the cognitive and real-world benefits of UFOV training in adolescents could lead to meaningful safety improvements for athletes as well as other adolescent populations who would benefit from enhanced visual processing abilities, such as adolescents learning to drive.