The development of a survey to examine knowledge about and attitudes toward concussion in high-school students

School Concussion Policy in Colorado: Lack of Knowledge and Access Are Barriers to Education

All states have youth sports concussion laws that have helped shape school concussion policy. However, state laws do not specify how schools distribute policy. The present study examined parent, youth, and school personnel's knowledge of school concussion policy in Colorado and ease of access to policy via school website. Youth (n = 1,987), parents (n = 520), and school personnel (n = 130) completed an online survey about knowledge of their schools' concussion policy. Less than half of parents (48.9%) and students (43.0%) knew their school had a policy. School personnel were aware of the policy (96%). Among youth, rates of knowledge differed across gender, school level, and sport participation. Forty-nine percent of school district websites contained information on concussion. There are gaps in knowledge of concussion policy for youth and their parents. Teachers, administrators, coaches, and school nurses, who are educated on policy, could help facilitate communication. School websites are not being fully utilized to disseminate concussion policy.

Concussion Knowledge, Attitudes, and Self-Reporting Intentions in Youth Athletes

CONTEXT

Although it has been suggested that developmental and sociological factors play a role in concussion reporting, the empirical evidence related to this is limited.

OBJECTIVE

To examine the influences of sex, school level, school location, concussion-reporting history, and socioeconomic status on concussion-related knowledge, attitudes, and reporting intentions among middle school and high school athletes.

DESIGN

Cross-sectional study.

SETTING

Master students and High School athletes attending pre-participation examinations (PPEs) were asked to complete paper-based surveys.

PATIENTS OR OTHER PARTICIPANTS

Overall, 541 athletes representing 18 sports returned fully completed surveys.

MAIN OUTCOME MEASURE(S)

Outcomes were concussion-related knowledge, perceived seriousness, positive feelings about reporting, and self-reporting intentions. We examined group differences in these outcomes across levels of the explanatory variables of sex, school level (middle school versus high school), school location (urban versus rural), concussion self-reporting history (yes or no), and socioeconomic status (free or reduced-price lunch versus no free or reduced-price lunch) using Wilcoxon rank sum tests. Then we used multivariable ordinal logistic regression models to identify predictors of higher score levels for each outcome. Odds ratio (OR) estimates with 95% confidence intervals (CIs) excluding 1.00 were deemed significant.

RESULTS

Odds of higher levels of knowledge were higher in urban versus rural school student-athletes (ORAdjusted = 1.81; 95% CI = 1.03, 3.17), and lower in student-athletes on free or reduced-price lunch versus those not on free or reduced-price lunch (ORAdjusted = 0.52; 95% CI = 0.36, 0.77). Similarly, odds of higher levels of seriousness were lower in male versus female student-athletes (ORAdjusted = 0.48; 95% CI = 0.32, 0.72). Further, odds of higher levels of self-reporting intentions were lower among male versus female student-athletes (ORAdjusted = 0.53; 95% CI = 0.37, 0.75).

CONCLUSIONS

Developmental and sociological factors were differentially associated with concussion-related knowledge, attitudes, and self-reporting intentions. These results can inform medical providers, parents, and coaches with regard to context-specific clinical assessments of concussion symptoms.

Association between concussion education and concussion knowledge, beliefs and behaviours among youth ice hockey parents and coaches: a cross-sectional study

OBJECTIVES

To examine the association between self-reported exposure to concussion education and knowledge, beliefs and self-reported behaviour among parents and coaches of youth ice hockey players.

DESIGN

Cross-sectional.

SETTING

Community ice hockey teams from Calgary and Edmonton, Alberta, Canada.

PARTICIPANTS

Parents and coaches of ice hockey players (ages 11-17, all divisions of play).

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants completed a questionnaire developed and validated to measure concussion knowledge, beliefs and concussion management behaviour (ie, coaches removing athletes from play; parents taking children with suspected concussions to physicians) consistent with the Health Action Process Approach (HAPA). The questionnaire examined specific HAPA constructs (ie, risk perception, outcome expectancies, action self-efficacy, intention, action planning, maintenance self-efficacy, recovery self-efficacy) relevant to concussion management behaviour.

RESULTS

Participants included 786 parents (31.8% with coaching experience) and 10 non-parent coaches. Of the participants, 649 (82.6%) previously received concussion education. Based on a multivariable regression analysis adjusting for coaching experience, previous history of a child sustaining one or more concussions, first aid experience and cluster by team, exposure to concussion education was associated with a mean score difference of 1.36 (95% CI 0.68 to 2.03), p<0.0001, in the knowledge score. Exposure to concussion education was not significantly associated with any of the HAPA constructs based on Wilcoxon rank-sum tests.

CONCLUSION

Exposure to concussion education may be associated with small overall differences in concussion knowledge but may not be associated with significant differences in beliefs or intended behaviours related to concussion management among youth hockey parents and coaches.When providing education or recommendations for concussion education sources to coaches and parents, educational strategies grounded in behavioural change theory that specifically target the motivators of behavioural change should be considered.

Using the Integrated Behavioral Model to Determine Sport-Related Concussion Reporting Intentions Among Collegiate Athletes

PURPOSE

A significant proportion of sport-related concussions goes unreported among adolescents, which can result in irreversible brain damage. It is critical to identify and intervene on factors that significantly impact concussion reporting.

METHODS

This study tests factors associated with collegiate athletes' intentions to (1) self-report concussion symptoms; (2) report another athlete's concussion symptoms; and (3) encourage others to report. Drawing on the Integrated Behavioral Model, predictors at the athlete level included perceived norms (bystander descriptive norms, injunctive norms, and subjective norms), attitudes (positive and negative expectancies about reporting and playing through a concussion and concussion reporting attitudes), personal agency (self-efficacy to recognize symptoms and communicate), and perceived coach communication. At the team level, coaches' self-reported communication was also included. Athletes (N = 1,858) and coaches (N = 254) at 16 colleges and universities completed Web-based surveys in 2016. Multilevel modeling accounted for the nesting of athletes within athletic team.

RESULTS

Bystander descriptive norms, positive reporting expectancies, concussion reporting attitudes, self-efficacy to communicate about a concussion, and athletes' perceptions of their coach's communication were positively associated with all three outcomes. By contrast, subjective norms were only positively associated with intentions to self-report and bystander reporting intentions, negative reporting expectancies were only associated with intentions to self-report, and positive and negative expectancies for playing through a concussion were only associated with intentions to self-report and bystander encouragement.

CONCLUSIONS

In sum, multiple factors within the Integrated Behavioral Model predict reporting intentions and underscore the complexity of athletes' concussion reporting behaviors and offer guidance for the development of prevention strategies.

Concussion disclosure in middle and high school youth: Who gets the message and are they trained to receive it?

Background

Disclosure of concussion is vital for proper diagnosis and treatment. Youth have many stakeholders to whom they may disclose concussion, including parents, peers, coaches, and school personnel. We examined whom high school and middle school youth report concussion and the level of concussion education of the recipients of the disclosure.

Methods

Data were analyzed from 2362 students, 680 parents, and 150 school personnel who completed an online survey about concussion reporting, education, and training.

Results

Youth were most likely to disclose concussions to parents, particularly mothers, and their peer group. Middle school youth reported to teachers and school nurses at higher rates than high school youth. High school youth were more likely to disclose concussion to coaches and athletic trainers than middle school youth. While mothers were the most likely recipient of youths’ reporting, they were least likely to have received concussion education.

Conclusions

Recipients of youth concussion disclosure differs by school level. Parents are the most common recipients of disclosure. The role of school personnel and coaches changes as youth enter high school. Youth primarily report concussions to parents, yet parents receive the least amount of concussion training. These findings highlight the need for targeted concussion training for stakeholder groups as their role in disclosure may differ by school age.

Return-to-Learn Accommodations and Concussion Perceptions Among Indiana High School Principals

OBJECTIVE

Care after concussion is important for all patients, although especially critical in children and adolescents because of continued rapid brain growth and maturation. Postconcussion symptoms often lead to impaired school performance. Conflicting data regarding best return-to-learn practices make it difficult for school administrators to develop policies to best accommodate concussed students. We sought to assess high school principals' knowledge of concussion, the personnel responsible for implementing accommodations, and the overall willingness to enact recommended academic accommodations.

METHODS

In our cross-sectional study, we surveyed 410 Indiana high school principals (157 responded). Assistant principals were excluded.

RESULTS

One-third of the respondents received academic accommodations training for concussed students and more than 80% were somewhat or very comfortable with academic management. Greater than 90% were willing to provide accommodations as long as necessary. However, nearly 40% of responding principals were unlikely or unwilling to implement accommodations for standardized testing. National and state data suggest the median Indiana high school should expect 30 and more concussions per year; more than 90% of principals estimated that fewer than 30 concussions occurred each year at their school.

CONCLUSIONS

The underestimation of concussion frequency highlights an opportunity for further education of high school principals to ensure all concussed students receive appropriate return-to-learn accommodations.

The youth concussion awareness network (You-CAN) - a school-based peer-led intervention to improve concussion reporting and social support: the protocol for a cluster randomized trial

Background

Concussion prevalence is increasing in the pediatric population, and is a matter of public health concern. Concussion symptoms can be physical, cognitive, emotional and behavioural, and last longer in high school aged youth than adults. Concussions are underreported in youth due to their lack of knowledge, social environment, perceived outcomes of reporting, norms, and self-efficacy. The Youth Concussion Awareness Network (You-CAN) is a school-based peer-led program designed to increase high school students’ intent to report a concussion, and provide social support to a peer. This study aims to investigate whether participation in You-CAN, a program grounded in service learning principles, impacts concussion knowledge, attitudes, intent to report a suspected concussion to an adult, and intent to provide social support to a peer. Secondary aims include assessing the implementation fidelity and acceptability of the intervention.

Methods

This longitudinal study will use a cluster randomized trial design. Three high schools from six randomly selected Canadian school boards will participate and be randomized to three study arms: (1) You-CAN led by school staff; (2) You-CAN led by school staff and research team; and (3) untreated comparison group. Intervention arms 1 and 2 will deliver the You-CAN program and create a Concussion Council at their school. The Concussion Council will deliver a concussion awareness campaign and participate in an online showcase with other participating schools. In addition, arm 2 will have monthly video-calls with the research team. A survey based on the Theory of Planned Behaviour will be administered school-wide with all arms (1, 2, 3) at two time points (beginning {T₀} and end {T₁} of the school year). Exit interviews will be completed with the Concussion Councils and participating school staff.

Discussion

This study will provide evidence of the effectiveness of a school-based peer-led concussion program on increasing concussion knowledge, attitudes, subjective norms, perceived behavioural control, intent to report a concussion to an adult, and intent to provide social support to a peer amongst Canadian high school students. It will also provide important information about the implementation and acceptability of the You-CAN program for high school students and staff.

Trial registration

This trial is registered with the ISRCTN registry (ISRCTN64944275, 14/01/2020, retrospectively registered).

Effectiveness of the US Centers for Disease Control and Prevention HEADS UP coaches' online training as an educational intervention

BACKGROUND

Concussions are common among youth athletes. Responsibility for the recognition and management of concussion is often put on coaches. To equip coaches with appropriate knowledge and skills, the US Centers for Disease Control and Prevention (CDC) launched the HEADS UP: Concussion in Youth Sports online training.

OBJECTIVES

To determine whether HEADS UP coaches' training improves knowledge, attitudes and behavioural intentions.

METHODS

Knowledge questions were grouped into scales by level of difficulty. Differences between pre-and post-test scores were calculated based on the Wilcoxon Signed Rank Test Z-score and effect sizes were interpreted.

RESULTS

Coaches displayed a high level of knowledge in the pre-test. While lower difficulty questions did not show improvement from pre- to post-test, moderate and high difficulty questions did. Use of the training was associated with improved knowledge about symptom resolution, return-to-play recommendations and under-reporting of incidents of concussion. Coaches demonstrated improvement in five of the seven concussion-related attitude and behavioural intention items post training.

CONCLUSION

HEADS UP training improved coaches' knowledge on select topics and helped them feel more comfortable about responding to concussion among their athletes. This study provides insight into how to better focus future HEADS UP concussion health education efforts to fit coaches' informational needs.

Towards an embedded symptom validity indicator for the rivermead postconcussion symptom questionnaire

This simulation study aimed to develop and test an embedded symptom validity indicator for use with the Rivermead Post Concussion Symptoms Questionnaire (RPQ). Seven mild traumatic brain injury (mTBI) experts assisted in generating a shortlist of 15 atypical postconcussion symptoms. A modified RPQ (mRPQ) was constructed by embedding these items with the 16 standard RPQ items. Eighty-four mTBI simulators completed the mRPQ after random allocation to a symptom-exaggeration condition (ES group; n = 46) or simulation-only condition (S group; n = 38). They also completed the Test of Memory Malingering (TOMM) and the Recognition Memory Test (RMT), and the groups were re-formed and compared using modified criteria for Malingered Neurocognitive Dysfunction (mMND). There was no significant group by item-type interaction for either grouping methods (i.e. as allocated or as reclassified). Exploratory analyses of the main effects showed that ES group had higher mRPQ scores than the S group, and standard symptoms were endorsed more than atypical symptoms. If further developed, the mRPQ could eventually aid the screening of PCS over-reporting.

Reporting Skill: The Missing Ingredient in Concussion Reporting Intention Assessment

BACKGROUND

Extant literature suggests that a substantial portion of athletes may not report a possible concussion and that concussion knowledge is insufficient to predict concussion reporting behavior. One area that has not been explored is reporting skill; that is, mastery of the actions required to report a concussion. This study evaluated the relationship between reporting skill and reporting intention, introducing a measure of the reporting skill construct.

HYPOTHESES

Reporting intentions will be more closely associated with reporting skill than with concussion/symptom knowledge. The relationship between concussion (or symptom) knowledge and reporting intentions will differ by level of reporting skill.

STUDY DESIGN

Repeated cross-sectional study.

LEVEL OF EVIDENCE

Level 2.

METHODS

A set of items was administered to young adults aged 18 to 24 years from the Survey Sampling International panel. Exploratory/confirmatory factor analyses were conducted on 2 waves of data to develop the scale (n = 899). Hypotheses were tested using structural equation modeling on the responses from the third wave of participants (n = 406).

RESULTS

Knowing the actions to take in reporting was more important than having knowledge of concussions or concussion symptoms. Reporting skill, not concussion or concussion symptom knowledge, was associated with higher intentions to report symptoms. Among those with higher levels of reporting skill, concussion symptom knowledge (but not general concussion knowledge) was associated with higher intentions to report symptoms.

CONCLUSION

Reporting skill is an important and, until now, missing ingredient in the concussion literature and practice.

CLINICAL RELEVANCE

Incorporating reporting skill development in concussion education and team activities to teach athletes how to report is likely to improve actual reporting intentions. While further study is needed with particular sports and additional age groups, reporting skill holds promise as a new avenue for increased concussion reporting.

Relationship of athletic and academic identity to concussion reporting intentions

BACKGROUND

Understanding concussed athletes' motivations for reporting concussion symptoms is important for health care professionals who are charged with the care, management, and prevention of future injury.

OBJECTIVES

To examine if athletic and academic identity predict concussion symptom reporting intentions above and beyond traditional socio-cognitive predictors.

DESIGN

Cross-sectional study using self-report measures during the 2016 collegiate football season.

METHOD

In a sample of National Collegiate Athletic Association (NCAA) Division I American football athletes (N = 205) we examined the relationship of athletic and academic identity with three indices of symptom reporting behavior: reporting during a game, reporting 24 h after a game, and reporting on behalf of a teammate. We used descriptive statistical analyses, correlations, and linear regression to examine hypotheses.

RESULTS

Controlling for traditional predictors, athletic identity was associated with a lower likelihood to report symptoms during a game (β = -0.22, t = -3.28, p < .001) or within 24 h (β = -0.28, t = -4.12, p < .001). Academic identity was positively associated with reporting intentions during a game (β = 0.12, t = 1.68, p < .05), 24 h later (β = 0.13, t = 1.85, p < .05), and on behalf of a teammate (β = 0.22, t = -3.36, p < .001).

CONCLUSIONS

Athletic and academic identities offer additional insight into athletes' motivation for concussion symptom reporting intentions, above and beyond traditional socio-cognitive predictors. Discussion focuses on the benefit of incorporating these important self-identities into educational health interventions to improve their impact.

Predictors of Collegiate Student-Athletes' Concussion-Related Knowledge and Behaviors

OBJECTIVE

This study aimed to explore student-athletes' concussion-related knowledge and attitudes toward reporting symptoms, demographic predictors of knowledge and attitudes, and determine whether responses to the survey changed following an online educational intervention.

METHODS

A total of 108 Division I student-athletes enrolled at a large southern university completed a survey evaluating knowledge regarding concussion-related terminology, symptoms and recovery trajectories, as well as attitudes toward reporting symptoms following a possible concussion. Student-athletes completed the questionnaire both 24-48 h before and one week after reviewing the educational presentation.

RESULTS

At baseline, participants correctly identified 72% of concussion symptoms included in the questionnaire, as well as correctly identified 75% of items related to the typical recovery trajectory post-concussion. A total of 54% of baseline attitudes toward reporting symptoms matched clinical best practices. Multiple analysis of variance (MANOVA) revealed that male sex and non-Caucasian race were associated with worse baseline knowledge of concussion symptoms. Concussion knowledge was not associated with attitudes toward reporting symptoms. Paired samples t-tests indicated that knowledge of concussion-related terminology improved modestly following the educational presentation.

CONCLUSIONS

Some subsets of collegiate student-athletes show relatively lower knowledge about symptoms of concussion than others. As a result, these groups may benefit from increased educational efforts to ensure they recognize when a concussion may have occurred. Additionally, as knowledge and attitudes were unrelated and the intervention had a modest effect on knowledge but not attitudes, future work should explore interventions that are designed to directly alter attitudes.

Investigation of strategies to improve concussion reporting in American football

While research on sport-related concussion has increased dramatically over the past decade, research investigating concussion reporting is in its early stages. The purpose of this project was to assess concussion reporting and work with stakeholders to develop and assess strategies to improve reporting. We used a multi-site, repeated measures design with three NCAA Division I football programs, including 223 athlete participants. A modified community-based participatory research (CBPR) approach was used to develop intervention strategies (Fall 2017 season) with stakeholders designed to increase concussion reporting intentions. Preseason and postseason surveys were administered to determine effectiveness. Main outcome measures included concussion knowledge, intervention effectiveness, and reporting intention measures. For all three programs, concussion knowledge was unrelated to reporting intentions. Two of the three programs implemented the intervention strategies and for these programs there was evidence that the interventions were effective. Specifically, athletes from these two programs perceived more support from coaches about reporting (P< 0.05; t= 2.83), received education more frequently (P< 0.05; t= 2.67), and reported being more likely to report concussion symptoms (P< 0.05; t= 2.14). Our study demonstrates that working with stakeholders to develop site-specific strategies to improve concussion reporting is an effective approach to help improve reporting behaviours.

Educational concussion module for professional footballers: from systematic development to feasibility and effect

Objectives

To describe: (1) how we developed a concussion module and (2) whether the concussion module is feasible (in terms of relevance, added value and suitability) and enhances knowledge and changes attitude of professional footballers about concussion.

Developing the concussion module

We developed the concussion module based on two structured and systematic processes. First, our needs assessment (questionnaire and interviews) in professional football (especially players) revealed that a 5–10 min concussion module was needed, ideally disseminated during club visits. Second, the objectives were defined (from published literature and by experts) as to disseminate essential information about what concussion is (definition), how to recognise it and the importance of removing a player with (suspected) concussion from the football field. We included an introductory video featuring a high-profile professional footballer and an animated educational component on defining concussion, recognising it and removing affected players from the field.

Feasibility and effect

A quasiexperimental study (pretest post-test design) was conducted among 61 professional footballers. These players were asked to complete two questionnaires related to knowledge about and attitude towards concussion and feasibility of the module: one before and one after viewing the concussion module. Potential increase in knowledge and attitude was explored by comparing the pretest and post-test scores of the Rosenbaum Concussion Knowledge and Attitudes Survey with the non-parametric Wilcoxon signed-rank test (p<0.05). The mean knowledge score of the participants was stable between tests (Z=213; p=0.16), while mean attitude score increased significantly (Z=331; p=0.01). Nearly all participants (85%–100%) were positive about the relevance, added value, duration and form of the concussion module.

Conclusion

The developed educational concussion module leads to better attitude of professional footballers towards concussion.

Evaluation of a theory-based concussion education program for secondary school student-athletes in Ireland

Concussion education is an important aspect of concussion prevention. The purpose of this study was to investigate the effect of a novel, theory of planned behavior (TPB)-driven concussion education program on secondary school athletes' concussion-reporting relevant cognitions immediately post-intervention and at 3 months follow-up. Data were collected from 428 secondary school athletes during the 2016-2017 academic year: 229 were assigned to an intervention group of which 59 (25.76%) completed assessments at all timepoints; 199 were assigned to a control group of which 153 (76.88%) completed assessments at all timepoints. Using repeated measures ANOVAs, we examined differences in athletes' concussion-reporting cognitions, by group and gender. The program had a significant positive effect on athletes' knowledge (P < 0.01), perceived behavioral control over concussion recognition and reporting (P < 0.01), and reporting intention (P < 0.01). These results were maintained at 3 months follow-up, with the exception of perceived behavioral control. The program did not have a significant effect on athletes' attitudes toward concussion reporting and subjective reporting norms. Results suggest that the TPB may be a useful framework to inform the development of more effective educational programs. There is a need for multi-layered interventions that aim to create sporting environments that encourage positive concussion care seeking behaviors.

Gender differences in concussion-related knowledge, attitudes and reporting-behaviours among high school student-athletes

BACKGROUND/AIM

Sport-related concussion is associated with various short- and long-term health consequences, especially among adolescent athletes. Yet, many concussions go unreported and/or unrecognised. The purpose of this study was to assess high school athletes' concussion-related knowledge, attitudes, intentions and reporting behaviours, and to explore whether gender differences are evident.

METHODS

A total of 435 high school athletes (52.2% female; mean age, 14.55 ± 1.67 years) participated in the survey. Questions assessed athletes' knowledge, attitudes, reporting intention and reporting behaviours, in respect to sports-related concussion. Comparisons between male and female athletes were explored using Mann-Whitney tests and chi-squared (χ²) tests as appropriate.

RESULTS

We found that 60% of the participants stated that they have played in practice or during a game (this season) with concussion symptoms. Males expressed more negative outcomes of concussion reporting and lower concussion reporting intention, compared to females. We found no significant gender differences in concussion-reporting behaviours.

CONCLUSION

Our findings suggest that knowledge, favourable attitudes towards reporting and reporting intention alone are not enough to create an environment that encourages the disclosure of concussion symptoms. Health promotion communication campaigns, coupled with concussion education and awareness programmes, should be utilised to further highlight the importance of timely concussion management, and to create a culture in which the reporting of concussion is considered normative.

Physical Education Teachers' Awareness and Understanding of Concussions, and Concussion Policies and Protocols

PURPOSE

Our primary aim was to determine physical educators' current level of understanding of concussion symptoms and response guidelines.

METHOD

Participants included 404 in-service physical educators (137 male, 266 female, 1 other) recruited through 3 SHAPE America - Society of Health and Physical Educators communication outlets. Participants were asked to complete an online survey. The survey included 8 questions related to previous concussion training, 6 items to measure awareness of concussion policies, 20 items related to concussion symptoms, and 14 items for concussion knowledge. Analyses included descriptive statistics and 2 × 2 (Coaching × Concussion) factorial analyses of variance to examine differences in study variables by coaching status and participants' personal concussion experiences.

RESULTS

Participants reported they did not have any formal role or responsibility related to concussion management, and more than half reported their districts did not require concussion training. Nevertheless, many physical educators were receiving training (n = 291, 72%). Participants who also coached were more aware of concussion policies and systems than were their counterparts, but there were no differences related to concussion facts.

CONCLUSION

School districts are generally not requiring concussion management training for physical education teachers or giving them specific responsibilities in the management process, yet many physical educators are getting trained. This training often occurs online and may be required for secondary responsibilities such as coaching. Participants reported being aware of concussion policies and procedures but were less likely to agree that this awareness has resulted in changes in how they teach physical education. Participants also knew more about concussion facts than about the legitimacy of symptoms.

Using Community Detection Analysis to Elucidate Caregivers’ Mental Models of Pediatric Concussion Symptoms

Due to a culture of resistance around concussion reporting, novel methods are needed to reveal implicit beliefs that could affect symptom reporting. The goal of this study was to elucidate caregivers’ mental models of pediatric concussion symptoms using an exploratory community detection analysis (CDA). Caregivers (n = 76) of adolescents 10–15 years old participated in a survey that assessed their intentions of seeking medical treatment for 12 injury symptoms following their child’s involvement in three hypothetical injury scenarios. We used a series of analyses of variance (ANOVAs) to compare injury symptoms across these scenarios and CDA to determine if caregivers implicitly group symptoms together. We then used logistic regressions to further explore associations between the CDA-identified symptom indices and known factors of injury risk. There were no differences in the likelihood to seek treatment for symptoms across injury scenarios; however, the CDA revealed distinct symptom clusters that were characterized by the degree of risk for non-treatment and symptom type. We observed associations between injury risk factors and intentions of seeking medical treatment for the higher-risk indices. Results indicate that caregivers’ mental models of concussion symptoms are nuanced, not monolithic. Therefore, it is inaccurate to measure intentions to seek treatment for concussion without taking these nuances into consideration.

Concussion knowledge, attitudes and reporting intention among adult competitive Muay Thai kickboxing athletes: a cross-sectional study

BACKGROUND

Muay Thai kickboxing is a full-contact combat sport with a high incidence of head trauma, yet little is known about these athletes' concussion knowledge and attitudes. This study aims to describe and quantify concussion knowledge, attitudes, and reporting intention among adult competitive Muay Thai kickboxing athletes.

RESULTS

This cross-sectional study comprised 193 competitive Muay Thai kickboxing athletes aged ≥18 years registered with the Thai Boxing Association Sanctioning Authority. The mean concussion knowledge score was 19.5 (SD 2.3) out of 25, the mean concussion attitudes score was 62.7 (SD 7.4) out of 75, and 134 (69.4%) of respondents indicated that they were likely to report concussion symptoms. No significant predictors of concussion knowledge, attitudes, or reporting intention were revealed.

CONCLUSIONS

Competitive Muay Thai kickboxing athletes appear to have reasonably good concussion knowledge, attitudes, and reporting intention; however, there is still room for further improvement. It is recommended that concussion education programs based on current best evidence are made available to all kickboxing athletes and coaches.

Sandbagging on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) in a high school athlete population

The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is a computerized neuropsychological test battery commonly used to assess cognitive functioning after a concussion. It is recommended that application of ImPACT utilizes a baseline administration so athletes have an individualized baseline with which to compare post-injury results should they sustain a concussion. It has been suggested that athletes may provide suboptimal effort, called "sandbagging," in order to return to their baseline cognitive scores, and thus to play, more quickly. This research examines ImPACT baseline scores when high school athletes were asked to attempt to "sandbag," and compares those scores with scores obtained when they were asked to give their "best effort." Fifty-four high school student athlete volunteers participated in the study. In contrast to previous research that just looked at the cut-score invalidity indicators built into ImPACT, this research developed a regression equation to predict sandbagging. A logistic regression equation developed with four variables that demonstrated the largest effect size between "best effort" and "sandbagged" baselines showed a 99.7% classification accuracy for the "best effort" and "sandbag" groups.

Exploring concussion awareness in hockey with a First Nations community in Canada

OBJECTIVE

The purpose of this pilot study was twofold: (1) to begin to understand concussion in youth hockey in a First Nations community in Canada and (2) to determine the impact of a novel concussion education workshop.

DESIGN

A one-group quasiexperimental time series study was undertaken.

SAMPLE

A total of 41 participants consented, with 71% (n = 29) completing data collection at all three study time points.

MEASUREMENT AND INTERVENTIONS

Two nurses one from the First Nations community and one from the tertiary care center collaborated to develop and deliver the intervention on concussion specifically general, hockey and symptom knowledge. The primary outcome was Total Knowledge Score (TKS), whereby correct responses to a self-reported questionnaire were summed and then converted to a percentage.

RESULTS

The TKS were similar across study time points; preworkshop 71.7%, postworkshop 71.8%, and 6-month follow-up 72%.

CONCLUSIONS

Nurses worked collaboratively with cultural experts from a First Nations community to integrate Indigenous ways of knowing into concussion awareness and safety for First Nations youth playing hockey.

Investigation of the Rosenbaum Concussion Knowledge and Attitudes Survey in Collegiate Athletes

OBJECTIVE

The purpose of this study is to determine whether the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) is an appropriate outcome measure to assess knowledge and attitudes toward concussion in collegiate student-athletes as determined through validity and reliability testing.

STUDY DESIGN

Convenience study.

SETTING

The researcher recruited all athletic teams at a Division III National Collegiate Athletic Association institution.

PARTICIPANTS

Four hundred thirty-three collegiate student-athletes, 18 years of age or older, from a variety of sports took part in this study. As the validity of RoCKAS has never been established for the target population, this study randomly split respondents into 2 studies.

INTERVENTIONS

Participants in this study completed the RoCKAS during preseason meetings before concussion education. The primary researcher was not present during the completion of the survey to allow participants to answer honestly without concern of coercion.

MAIN OUTCOME MEASURES

A paper-based Rosenbaum Concussion Knowledge and Attitudes Survey.

RESULTS

The Concussion Knowledge Index (CKI) was distributed in 2 cluster constructs and identified variables of low and high difficulty. Multivariate statistical analysis of the Concussion Attitude Index (CAI) explains 68.79% of the total variance. The Confirmatory Factor Analysis did not confirm the hypothesis that similar constructs can be found between data sets ((Equation is included in full-text article.)= 207.902; consistent akaike information criterion = 391.550; root mean square error of approximation = 0.125, and goodness of fit index = 0.868).

CONCLUSIONS

The CKI is a valid and reliable measure in collegiate student-athletes. However, the results of the Confirmatory Factor Analysis indicated a poor model fit and improper correlations between attitude items. Therefore, the CAI may not be a sound outcome measure of collegiate student-athlete's attitudes toward concussions.

Comparison of knowledge, perception and attitudes of concussion in previously concussed versus non-concussed youth soccer players

OBJECTIVES

To examine if history of concussion is correlated with a difference in knowledge, attitude, and perception of concussive injuries in youth soccer players.

METHODS

A convenience sample of youth soccer athletes aged 14 to 18 years completed a survey assessing prior history of concussive injury, knowledge of concussive injury, self-reporting attitudes, and perception of the injury. The survey consists of 16 knowledge questions (eleven on a scale of 1-2, and five on a scale of 1-4) and 12 attitude questions (seven on a scale of 1-4, and five on a scale of 1-5). The primary outcomes are the total scores calculated by summing the standardized raw scores for all knowledge questions and attitude questions, respectively. Linear regression was used to estimate the mean difference in the primary outcomes between previously concussed and non-concussed athletes (calculated as previously concussed - non-concussed).

RESULTS

Surveys were obtained from 90 athletes, with 32 (36%) previously sustaining at least one concussion. Thirty-one out of these 32 concussions were diagnosed by a medical provider. On average, the mean total raw scores of all knowledge questions are 34.6 (82.2% of 42 possible points) and 33.7 (80.2% of 42 total points) for previously concussed and non-concussed athletes, respectively, and the mean total raw scores of all attitude questions are 38.7 (72.9% of 53 possible points) and 39.6 (74.7% of 53 possible points), respectively. Mean differences estimated from univariate linear regression in the standardized total scores of knowledge questions and attitude questions are 1.56(95% confidence interval: -1.52-4.65) and -1.23 (%95 confidence interval: -4.64-2.19), respectively. Adjusting for age and years of playing soccer gave similar results.

CONCLUSION

Although we did not find significant differences between previously concussed and non-concussed athletes in either the knowledge or the attitude questions as measured by their total scores, this study showed a high level of awareness of concussion in youth soccer players, while still highlighting a need for education. Limited distinctions were made among subgroups of players, suggesting directions of future research in investigating the role that outside factors may have on knowledge and perception of concussion.

Concussion Knowledge and Communication Behaviors of Collegiate Wrestling Coaches

Sport coaches can play an important role in shaping a team's approach to concussion safety through their communication with team members. However, across all sports, there is limited knowledge about factors that make coaches more or less likely to engage in safety-supportive communication. The objectives of this study were to assess the concussion-related knowledge and attitudes of wrestling coaches, as well as the extent to which they engage in autonomy-supportive coaching practices, and to determine how these factors are related to communication with athletes in support of concussion safety. Data were collected through an online survey of head coaches of National Collegiate Athletic Association (NCAA) wrestling teams (n = 89, 40.5% response rate). On average, coaches answered five out of a possible nine knowledge questions correctly and were significantly more likely to think it was acceptable for an athlete to continue playing after sustaining a concussion during a national qualifying competition as compared to during an early-season competition. Engaging in autonomy-supportive coaching behaviors was the coach factor explaining the largest percentage of variability in communication. Findings suggest that while knowledge deficits and attitudes about the acceptability of continued play while symptomatic during more consequential competitive matches should be addressed in educational programming for collegiate wrestling coaches, these changes alone may not be a sufficient for adequately increasing concussion safety communication. Targeting more distal factors such as autonomy-supportive approaches to coaching may hold promise for intervention design and should be explored in future prospective research.

Mandated High School Concussion Education and Collegiate Athletes' Understanding of Concussion

CONTEXT

  Concussions in student-athletes are a serious problem. Most states have enacted legislation mandating concussion education for student-athletes, under the assumption that education leads to better self-reporting of concussions and improved knowledge of symptoms.

OBJECTIVES

  (1) To determine the effect of state-based concussion legislation on the proportion of student-athletes receiving concussion education and to assess the moderation of this effect by gender and sport and (2) to assess the effect of concussion education on student-athletes' knowledge of concussion symptoms and likelihood of seeking treatment after a concussion.

DESIGN

  Cross-sectional study.

SETTING

  Private university.

PATIENTS OR OTHER PARTICIPANTS

  A total of 249 National Association of Intercollegiate Athletics collegiate athletes attending St Xavier University; 160 were surveyed prelegislation and 89 were surveyed postlegislation.

MAIN OUTCOME MEASURE(S)

  Participants completed an anonymous survey that assessed previous involvement in concussion-education programs, degree of self-reporting after a concussion, and ability to enumerate symptoms.

RESULTS

  The number of athletes who reported having received education increased after the implementation of concussion legislation; however, almost 25% still reported not having received education. Athletes who played football were more likely to report having received education than those who played volleyball. The student-athletes' ability to name a diversity of concussion symptoms or to report seeking medical attention after a concussion did not improve in the postlegislation period relative to the prelegislation period.

CONCLUSIONS

  Legislation has been passed in all 50 states to address concussions in student-athletes; however, improvements are still needed. Concussion education must be delivered in a uniform, effective manner to all student-athletes across sports and genders. Concussion education should emphasize the diversity of symptoms, especially cognitive and behavioral symptoms. We must develop and disseminate evidence-based educational programs that are clinically proven to be effective in improving athletes' knowledge and behaviors.

Concussion reporting, sex, and conformity to traditional gender norms in young adults

This study assessed whether between-sex differences in concussion reporting intention and behavior among young adults are explained by the extent to which the individual conforms to traditional masculine norms that often characterize contemporary sport culture. A survey of college athletes in the United States (n = 328) found greater symptom reporting intention among females as compared to males, but no difference in their likelihood continued play while experiencing symptoms of a possible concussion. Greater conformity to the norms of risk-taking was associated with greater likelihood of continued play while symptomatic among female athletes but not among male athletes. These findings suggest that gendered behavior, rather than biologically determined sex, is an important consideration for concussion safety in this age group. Addressing elements of the contemporary sport ethos that reinforce risk taking in service of athletic achievement may be a relevant direction for interventions aimed at improving injury reporting among all athletes.

Concussion Management in the Classroom

There is a new emphasis on the team approach to pediatric concussion management, particularly in the classroom. However, it is expected that educators are unfamiliar with the "Returning to Learning" recommendations. The authors' primary objective was to assess and improve high school educators' knowledge regarding concussions and management interventions using an online education tool. A total of 247 high school educators completed a 12 question pretest to assess core knowledge of concussions and classroom management followed by a 20-minute online literature-based education module. Participants then completed an identical posttest. The improvement in core knowledge was statistically significant (P < .001). Initial areas of weakness were the description and identification of concussions. Questions regarding concussion classroom management also showed a statistically significant increase in scores (P < .001). This study identifies the deficits in the knowledge of educators regarding concussions and classroom management as well as the significant improvement after an online educational module.

Concussion reporting behaviours of community college student-athletes and limits of transferring concussion knowledge during the stress of competition

Concussion education for student-athletes is mandated by several states and is becoming an integral component of concussion management programmes; however, little is known about student-athlete concussion knowledge and self-reporting of suspected concussion. This study explored to what extent collegiate student-athletes are knowledgeable on the topic of concussion, the relationship between having concussion knowledge and reporting behaviours, and factors contributing to not reporting when education has been provided.

The Impact of a Concussion-U Educational Program on Knowledge of and Attitudes about Concussion

Background: The diagnosis of a sports-related concussion is often dependent on the athlete self-reporting their symptoms. It has been suggested that improving youth athlete knowledge and attitudes toward concussion may increase self-reporting behaviour. The objective of this study was to determine if a novel Concussion-U educational program improves knowledge of and attitudes about concussion among a cohort of elite male Bantam and Midget AAA hockey players. Methods: Fifty-seven male Bantam and Midget AAA-level hockey players (mean age=14.52±1.13 years) were recruited from the local community. Each participant completed a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey–Student Version immediately before and after a Concussion-U educational presentation. Follow-up sessions were arranged 4 to 6 months after the presentation, and assessed retention of knowledge and attitude changes. Results: Forty-three players completed all three surveys. Concussion knowledge and attitude scores significantly (p<0.01) increased from pre- to post-presentation by 12.79 and 8.41%, respectively. At long-term follow-up, knowledge levels remained significantly (p<0.01) higher than baseline by 8.49%. Mean attitude scores were also increased at follow-up; however, this increase was not statistically significant. Conclusions: A Concussion-U educational program led to an immediate improvement in concussion knowledge and attitudes among elite male Bantam and Midget AAA hockey players. Increased knowledge was maintained at long-term follow-up, but improved attitude was not. Future studies should investigate whether similar educational programs influence symptom reporting and concussion incidence. In addition, they should focus on how to maintain improved concussion attitudes.

English professional football players concussion knowledge and attitude

BACKGROUND

Concussions are a common pathology in football and multiple misconceptions exist amongst the players and managers. To address these misconceptions, and potentially reduce concussion associated sequela, effective educational interventions need to be developed. However, the current knowledge and attitude status must be ascertained to appropriately develop these interventions. The purpose of this study was to assess the concussion knowledge and attitude of English professional footballers.

METHODS

Twenty-six participants from one English Football League Championship club completed the study. A mixed methods approach included the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) and a semi-structured interview. The RoCKAS contains separate knowledge (0-25) and attitude (15-75) scores and was followed by a semi-structured interview consisting of concussion knowledge, attitude, and behavior related questions.

RESULTS

The mean score on the RoCKAS knowledge was 16.4 ± 2.9 (range 11-22) and the attitude score was 59.6 ± 8.5 (range 41-71). The interview responses identified inconsistencies between the RoCKAS and the intended behaviors, endorsing multiple concussion misconceptions, and revealed barriers to concussion reporting.

CONCLUSION

The results of this study suggest that Championship Level English footballers have moderate concussion knowledge, safe attitudes, and good concussion symptom recognition when assessed with pen and paper questionnaires. However, within the semi-structured interview many respondents reported unsafe concussion behaviors despite accurately identifying the potential risks. Further, multiple barriers to concussion reporting were identified which included perceived severity of the injury, game situations, and the substitution rule. These findings can help form the foundation of educational interventions to potentially improve concussion reporting behaviors amongst professional footballers.

High School Football Players' Knowledge and Attitudes About Concussions

OBJECTIVES

To assess high school (HS) football players' knowledge of concussions and to determine whether increased knowledge is correlated with better attitudes toward reporting concussion symptoms and abstaining from play.

DESIGN

Two survey tools were used to assess athletes' knowledge and attitudes about concussions. Surveys collected information about demographics, knowledge about concussions, and attitudes about playing sports after a concussion. All athletes present completed one of the 2 surveys. A knowledge and attitude score for each survey was calculated. Frequencies and mean values were used to characterize the population; regression analysis, analysis of variance, and t tests were used to look for associations.

SETTING

A football camp for HS athletes in the Cincinnati area.

PARTICIPANTS

Male HS football players from competitive football programs in the Cincinnati area.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Scores on knowledge and attitude sections; responses to individual questions.

RESULTS

One hundred twenty (100%) athletes were enrolled although not every athlete responded to every question. Thirty (25%) reported history of a concussion; 82 (70%) reported receiving prior concussion education. More than 75% correctly recognized all concussion symptoms that were asked, except "feeling in a fog" [n = 63 (53%)]. One hundred nine (92%) recognized a risk of serious injury if they return to play too quickly. Sixty-four (54%) athletes would report symptoms of a concussion to their coach; 62 (53%) would continue to play with a headache from an injury. There was no association between knowledge score and attitude score (P = 0.08).

CONCLUSIONS

Despite having knowledge about the symptoms and danger of concussions, many HS football athletes in our sample did not have a positive attitude toward reporting symptoms or abstaining from play after a concussion.

CLINICAL RELEVANCE

Physicians should be aware that young athletes may not report concussion symptoms.

An evaluation of Gaelic Athletic Association (GAA) athletes' self-reported practice of playing while concussed, knowledge about and attitudes towards sports-related concussion

BACKGROUND/AIM

Sports-related concussions are now recognized as a major public health concern. However, despite the association of concussion with short- and long-term health consequences, many young athletes still lack basic knowledge about concussion and seem to believe that concussions may be "toughed out" and do not require medical attention. This study assessed self-reported practice of playing in training or a match while concussed among Gaelic Athletic Association (GAA) athletes in Ireland aged 13-25 years old (M=19.19, SD=3.54). This study also assessed knowledge about and attitudes towards sports-related concussion in GAA players in Ireland.

METHODS

Using a self-report questionnaire, data were captured electronically on GAA athletes aged 13-25 years old (n=80) regarding knowledge about the detection, assessment and management of sports-related concussion, as well as participant's attitudes towards concussion and self-reported practice of playing in training or a match while concussed. Data were collected from June to August 2013.

RESULTS

This study revealed that approximately one in four athletes reported having played while concussed in practice or during a match. Males were significantly more likely to play while concussed than females (40.9% and 17.2%, respectively). Results from this study indicated participants lack a complete understanding of concussion, as common misconceptions about concussion prevailed. Analyses revealed that participants generally have safe attitudes towards concussion and concussion management.

CONCLUSION

Generating awareness of the potential short- and long-term health consequences of concussion, coupled with the promotion of safer attitudes towards this injury, could minimize the number of players who return-to-play pre-maturely and promote a more safety-conscious sports culture in Ireland.

Social norms theory and concussion education

Secondary prevention of harm from sport-related concussion is contingent on immediate removal from play post-injury. To-date, educational efforts to reduce the prevalent risk behavior of continued play while symptomatic have been largely ineffective. Social norms theory may hold promise as a foundation for more effective concussion education aimed at increasing concussion reporting. The primary objective of this study was to assess whether perceived team concussion reporting norms would be less supportive of an individual's safe concussion symptom reporting behavior than objective team norms. Participants were 328 male and female US collegiate athletes. Written surveys were completed in person during the spring of 2014. Among both male and female athletes, team concussion reporting norms were significantly misperceived, with athletes tending to think that they themselves have safer attitudes about concussion reporting than their teammates. Perceived norms were associated with symptom reporting intention, independent of the team's objective reporting norm. A social norms approach to concussion education, in which misperceived group norms are corrected and shifted in the direction of safety, is an important avenue for program development and evaluation research aimed at the secondary prevention of harm from concussion. Implications for the design of this type of educational programming are discussed.

Norms, athletic identity, and concussion symptom under-reporting among male collegiate ice hockey players: a prospective cohort study

BACKGROUND

Many athletes fail to report concussion symptoms to coaches or medical personnel, putting them at risk for potentially catastrophic neurologic consequences if additional brain trauma is sustained prior to full recovery.

PURPOSE

The purpose of this study was to determine whether concussion reporting norms prior to the start of the athletic season predicted reporting symptoms of a possible concussion during the season, and whether this association was moderated by athletic identity.

METHODS

Members of six National Collegiate Athletic Association Division 1 men's ice hockey teams (n = 116) completed written surveys before and after the 2012-2013 collegiate ice hockey season.

RESULTS

Participants who at pre-season perceived that "most athletes" were likely to report symptoms of a concussion were themselves more likely to report symptoms during the season. Athletic identity weakly moderated this association.

CONCLUSIONS

Perceived reporting norms may be an important target of interventions aimed at reducing symptom under-reporting among athletes.

Engaging Teammates in the Promotion of Concussion Help Seeking

Concussion underreporting contributes to the substantial public health burden of concussions from sport. Teammates may be able to play an important role in encouraging injury identification and help seeking. This study assessed whether there was an association between beliefs about the consequences of continued play with a concussion and intentions to engage as a proactive bystander in facilitating or encouraging teammate help seeking for a possible concussion. Participants were 328 (male and female) members of 19 U.S. collegiate contact or collision sports teams. Athletes who believed that there were negative health or performance consequences of continued play with a concussion were significantly more likely than their peers to intend to encourage teammate help seeking, but not more likely to alert a coach or medical personnel. Additionally, athletes who believed that their teammates were more supportive of concussion safety were more likely to intend to engage as proactive bystanders in encouraging teammate help seeking. Exploring how to encourage bystander promotion of concussion safety is an important direction for future programming and evaluation research and may provide an opportunity to improve the effectiveness of concussion education.

Concussion under-reporting and pressure from coaches, teammates, fans, and parents

Concussions from sport present a substantial public health burden given the number of youth, adolescent and emerging adult athletes that participate in contact or collision sports. Athletes who fail to report symptoms of a suspected concussion and continue play are at risk of worsened symptomatology and potentially catastrophic neurologic consequences if another impact is sustained during this vulnerable period. Understanding why athletes do or do not report their symptoms is critical for developing efficacious strategies for risk reduction. Psychosocial theories and frameworks that explicitly incorporate context, as a source of expectations about the outcomes of reporting and as a source of behavioral reinforcement, are useful in framing this problem. The present study quantifies the pressure that athletes experience to continue playing after a head impact--from coaches, teammates, parents, and fans--and assesses how this pressure, both independently and as a system, is related to future concussion reporting intention. Participants in the study were 328 male and female athletes from 19 teams competing in one of seven sports (soccer, lacrosse, basketball, softball, baseball, volleyball, field hockey) at four colleges in the northeast region of the United States. Results found that more than one-quarter of the sample had experienced pressure from at least one source to continue playing after a head impact during the previous year. Results of a latent profile mixture model indicated that athletes who experienced pressure from all four of the measured sources were significantly more likely to intend to continue playing in the future than were athletes who had not experienced pressure from all sources, or only pressure from coaches and teammates. These findings underscore the importance of designing interventions that address the system in which athletes make decisions about concussion reporting, including athletes' parents, rather than focusing solely on modifying the individual's reporting cognitions.

Assessment of parental knowledge and attitudes toward pediatric sports-related concussions

Background:

Parents of young athletes play a major role in the identification and management of sports-related concussions. However, they are often unaware of the consequences of concussions and recommended management techniques.

Hypothesis:

This study quantitatively assessed parental understanding of concussions to identify specific populations in need of additional education. We predicted that parents with increased education and prior sports- and concussion-related experience would have more knowledge and safer attitudes toward concussions.

Study Design:

Cross-sectional survey.

Level of Evidence:

Level 5.

Methods:

Participants were parents of children brought to a pediatric hospital and 4 satellite clinics for evaluation of orthopaedic injuries. Participants completed a validated questionnaire that assessed knowledge of concussion symptoms, attitudes regarding diagnosis and return-to-play guidelines, and previous sports- and concussion-related experience.

Results:

Over 8 months, 214 parents completed surveys. Participants scored an average of 18.4 (possible, 0-25) on the Concussion Knowledge Index and 63.1 (possible, 15-75) on the Concussion Attitude Index. Attitudes were safest among white women, and knowledge increased with income and education levels. Previous sports experience did not affect knowledge or attitudes, but parents who reported experiencing an undiagnosed concussion had significantly better concussion knowledge than those who did not.

Conclusion:

Parents with low income and education levels may benefit from additional concussion-related education.

Clinical Relevance:

There exist many opportunities for improvement in parental knowledge and attitudes about pediatric sports-related concussions. Ongoing efforts to understand parental knowledge of concussions will inform the development of a strategic and tailored approach to the prevention and management of pediatric concussions.

Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education

OBJECTIVE

This study aimed to evaluate whether preseason concussion knowledge and reporting intention predicted in-season concussion reporting behavior.

DESIGN

Prospective cohort study.

SETTING

Collegiate athletic facility of each participating team.

PARTICIPANTS

National Collegiate Athletic Association Division I men's ice hockey players in 1 conference of competition (n = 116).

INDEPENDENT VARIABLES

Intention to report symptoms of a "minor" concussion and concussion knowledge were assessed at preseason.

MAIN OUTCOME MEASURES

Postseason recall of non-report of postimpact symptoms.

RESULTS

Preseason concussion knowledge was not significantly associated with in-season reporting behavior. Intention to report concussion symptoms was significantly related to in-season reporting behavior. There was a significant interaction between the number of different symptoms experienced and both preseason reporting intention and in-season reporting behavior.

CONCLUSIONS

Evaluations of concussion education programs tend to measure concussion knowledge. The present findings suggest that reporting intention may be more strongly predictive of reporting behavior than concussion knowledge and should be included in evaluations of concussion effectiveness. New concussion education initiatives should consider targeting psychosocial constructs that increase reporting intention.

CLINICAL RELEVANCE

Sports medicine clinicians who are involved in evaluating concussion education programs should measure constructs other than just concussion knowledge. Intention, to report symptoms or to continue play while experiencing symptoms of a concussion, seems to be an important and feasible construct to include as part of proximal evaluations of education effectiveness.

High School Athletes' Perceptions of Concussion

BACKGROUND

The perception high school athletes have regarding concussions may influence their injury-reporting behavior, and if their perceptions are based on incorrect or incomplete information, they may be at risk for subsequent head injuries.

PURPOSE

To determine whether the recent influx of concussion information has had a positive impact on high school athletes' knowledge of concussions, to determine their perceptions regarding the severity of a concussion injury, and to determine whether receiving correct information will potentially alter their future reporting behavior.

STUDY DESIGN

Cross-sectional study; Level of evidence, 4.

METHODS

A total of 454 high school athletes (212 females, 242 males; mean age, 15.7 ± 1.15 years) from 6 different schools participated in an anonymous survey. The researchers met with teams individually at their high schools to collect data and provide an educational intervention regarding sports-related concussions. The survey questions assessed the athletes' personal injury histories and perceptions and knowledge of the severity of concussion injuries.

RESULTS

There was a difference in the number of athletes who reported having their "bell rung" (n = 297) versus the number of athletes reporting at least 1 concussion (n = 172) (t (453) = -11.60, P = .000, d = -0.54). There was also a difference in the number of athletes who reported a history of at least 1 concussion at the beginning of the study session (n = 172) versus the number of athletes who reported at least 1 concussion at the end of the session (n = 292) (t (453) = -12.018, P = .000, d = 0.732). Fifty percent of athletes also stated that the importance of a game/event should dictate when they return to play.

CONCLUSION

High school athletes continue to fail to realize when they have sustained a concussion. Additionally, athletes lack understanding regarding the severity and seriousness of a concussion. A better effort at formalized education must be made if the culture of sports is to change.

CLINICAL RELEVANCE

Allied health care professionals need to continue to put forth a great effort in educating all student athletes on what a concussion is and the dangers of a concussion injury. Preseason meetings should be used as an opportunity to provide formalized education to all student athletes.

Pilot Randomized Evaluation of Publically Available Concussion Education Materials

Many states and sports leagues are instituting concussion policies aimed at reducing risk of morbidity and mortality; many include mandates about the provision of concussion education to youth athletes. However, there is limited evidence if educational materials provided under these typically vague mandates are in fact effective in changing concussion risk-related behavior or any cognition predictive of risk-related behavior. The purpose of this pilot randomized controlled study was to conduct a theory-driven evaluation of three publically available concussion education materials: two videos and one informational handout. Participants were 256 late adolescent males from 12 teams in a single league of ice hockey competition in the United States. Randomization of educational condition occurred at the team level. Written surveys assessing postimpact symptom reporting behavior, concussion knowledge, and concussion reporting cognitions were completed by participants immediately before receiving their educational intervention, 1 day after, and 1 month after. Results indicated no change in any measure over any time interval, with the exception of perceived underreporting norms. In one of the video conditions, perceived underreporting norms increased significantly 1 day after viewing the video. Possible content and viewing environment-related reasons for this increase are discussed. Across all conditions, perceived underreporting norms increased 1 month after intervention receipt, raising the possibility that late in the competitive season underreporting may be perceived as normative. The need for the development of theory-driven concussion education materials, drawing on best practices from health behavior scholars, is discussed.