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

Gender differences in concussion-related knowledge, attitudes and reporting behaviors of varsity athletes

BACKGROUND

Concussion is a pathophysiological process that occurs due to a traumatic biomechanical force. Concussions are an "invisible" and common traumatic brain injury with symptoms that may be underestimated. This necessitates fundamental improvements in public knowledge specifically addressing young university athletes and different genders. This cross-sectional study aimed to explore the possibility of gender differences with respect to university student athletes' concussion knowledge, attitude and reporting behaviors. We hypothesized that there should be no significant difference in concussion knowledge among male and female student athletes; however, females would show a more positive attitude and more reporting behaviors than male student athletes.

METHODS

Overall, 115 university athlete students completed a survey questionnaire; we eliminated some participants based on required inclusion criteria of Rosenbaum Concussion Knowledge and Attitude Survey-student version (RoCKAS-ST). Our final analysis consisted of 96 participants: 20 males (mean age 21.15 years) and 75 females (mean age 22.36 years). This study included questions about the athletes' given reasons for reporting or not reporting a concussion. Additionally, 33 RoCKAS-ST questions on Concussion Knowledge Index (CKI) with fair test-retest reliability (r=0.67) and 15 items on Concussion Attitude Index (CAI) with satisfactory test-retest reliability (r=0.79) were provided.

RESULTS

Males reported more sources for learning about concussions and more sport-related reasons for reporting a concussion than females (P<0.05). Both genders provided equal numbers of reasons for neglecting a concussion report or not disclosing a concussion for the sake of others (i.e., family, teammates or the coach). Out of 16 given reasons for not reporting a concussion, males significantly chose sport-related reasons over female athletes (P<0.05). Additionally, by looking at the two components of RoCKAS-ST, the independent t-test results showed no significant gender-based differences in concussion knowledge and attitude indices (P>0.05). Nevertheless, females were less optimistic about evaluating other athletes' attitude over concussion reporting (P<0.05).

CONCLUSIONS

Our study indicated that concussion knowledge is not gender biased among Canadian university athletes; however, more investigation is required to learn how safe environments for concussion disclosure could encourage reporting the symptoms in varsity athletes, especially in males who are more susceptible to not reporting a concussion to not miss their sport-related goals.

Sport-related concussion attitudes and knowledge in elite English female footballers

BACKGROUND

Sport-related concussions (SRC) are more common and more severe in women's football than men's yet the knowledge and attitudes of SRC in the women's game are not well understood. The objective of this study was to assess the SRC knowledge and attitude in elite female footballers.

METHODS

An online questionnaire was sent to all registered players in the English Football Association Women's Super League (WSL) and Championship. Respondents completed an amended version of the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS). Concussion Knowledge Index (CKI) and Concussion Attitudes Index (CAI) scores were derived for all respondents.

RESULTS

One hundred and twenty-three players completed the survey with 111 fitting the inclusion criteria. The mean CKI score was 20.5 ± 2.3 and the mean CAI score was 63.3 ± 6.3. A weak positive correlation was shown between the CKI and CAI (r = 0.20; p = 0.03). Previous concussion education had a significant impact on increased knowledge (U = 1198; p = 0.04). There was no significant difference in concussion attitudes and knowledge between the WSL and Championship or in those with a previous concussion history and no previous concussion (p > 0.05).

CONCLUSION

Previous SRC education demonstrated an increased knowledge around concussion but a limited impact towards concussion attitudes. It is suggested that concussion education should be mandated across the professional game to enhance player welfare.

Sport-related concussion knowledge and attitudes of staff working in English elite women's football: a survey-based study

BACKGROUND

Sport-related concussion (SRC) remains an injury of concern in sport, including football(soccer). There has been little investigation into SRC knowledge and attitudes of support staff working in the professional setting.

METHODS

An amended version of the Rosenbaum Concussion Knowledge and Attitudes Survey(RoCKAS) was distributed online to coaching staff, and medical and performance staff, working at clubs in the English Football Association Women's SuperLeague (WSL) and Championship. Completion of the survey generated two scores: concussion knowledge index (CKI) and concussion attitudes index (CAI).

RESULTS

Sixty-three completed surveys were returned. Eighteen respondents were coaching staff, and 45 were medical and performance staff. The median CKI in medical and performance staff was significantly greater than in coaching staff. There was no significant difference in CAIbetween coaching staff and medical and performance staff. There was no correlation between CKI and CAI across all staff.

CONCLUSION

Medical and performance staff working in elite women's football have greater knowledge of SRC than coaching staff. However, this does not always translate into safe behaviours on the field. Education should continue to be mandated across the professional game amongst support staff in order to maximise player welfare and enhance injury outcomes, whilst also reinforcing present SRC guidance.

Determining Factors Influencing Collegiate Players' Intention to Pursue a Professional Career

The rise of professional careers in playing sports has been seen in the recent generation. Ranging from traditional sports to recent e-games, it can be seen that student athletes are not only considering these as motivational factors for education, but also as future career paths. This study aims to fill the knowledge gap about the factors influencing college athletes' aspirations to play professionally. The study examines the complex web of athlete decision-making by utilizing the extended Theory of Planned Behavior (TPB) and analyzing the roles of motivational factors, self-efficacy, affective behavior, and behavioral domains. With the use of structural equation modeling, the study deciphers the intricate links, emphasizing the critical role that attitude plays in affective behavior. It emphasizes how much optimism and self-efficacy shape an athlete's behavior and subsequent pursuit of professional careers. The current research provides a benchmark for future studies exploring student athletes' career goals. This research adds understanding to the knowledge gap regarding the complex decision-making procedures of aspiring professional athletes. Both theoretical and practical implications are provided based on the results of the study, which stakeholders and institutions may consider for student athletes wanting to pursue a professional sports career.

Collegiate student-athletes concussion knowledge and attitudes: what a difference a decade Makes

OBJECTIVE

The purpose of this study was to assess changes in concussion knowledge and attitudes amongst incoming intercollegiate student-athletes over the course of a decade (2010-2012 vs 2021-2023).

METHODS

There were 592 student-athletes from 2 cohorts (2010-2012, 2021-2023) who completed the Rosenbaum Concussion Knowledge and Attitudes Survey (ROCKaS) questionnaire which is comprised of a concussion knowledge index (CKI, 0-24) and attitude index (CAI, 15-75) with higher scores reflecting better performance. A three factor ANOVA (Group, Sex, Concussion History) compared performance on the CKI and CAI. Individual questions were compared between groups with a Chi-Square analysis.

RESULTS

For the CKI, there was a significant main effect for Group (2010-2012: 18.5 ± 2.6, 2021-2023: 19.4 ± 2.5, p < 0.001, η 2 = 0.032 ) . For the CAI, there was also a significant main effect for group (2010-2012: 52.9 ± 6.0, 2021-2023: 62.2 ± 6.5, p < 0.001, η 2 = 0.359 ) .

CONCLUSIONS

The results of this study show a modest increase in concussion knowledge; however, large improvements in concussion attitudes were observed between groups. These results suggest a continued improvement in student-athlete concussion awareness and provide specific areas to continue addressing persistent misconceptions.

A international cross-sectional study examining knowledge and attitudes towards sport-related concussion in Touch

OBJECTIVE

To determine the current level of knowledge and attitudes towards sport-related concussion (SRC) amongst key stakeholders in touch rugby.

DESIGN

An international cross-sectional study. Participants n = 141 (male, n = 88; female, n = 53) from 15 Touch Associations.

MAIN OUTCOME MEASURE

Online questionnaire including non-validated sections captured participant characteristics, first aid training, previous concussion, awareness of SRC guidelines, combined with Rosenbaum Concussion Knowledge and Attitudes Survey. Distributed online to Touch athletes internationally. Concussion knowledge index (CKI) and attitude index (CAI) scores were calculated. A linear regression was performed to determine whether awareness of concussion, previous concussion and role affected CKI and CAI scores.

RESULTS

Median CKI and CAI scores were 21 ± 2.0 and 67 ± 6.3, respectively, across all key stakeholders. 39% of participants reported a previous SRC and 32% of respondents were aware of concussion guidelines form their Association. Regression analysis showed minimal influence of key contextual information on CKI and CAI.

CONCLUSIONS

Findings suggest that key stakeholders in Touch have high to very high knowledge and safe attitudes towards SRC. However, there were some areas where further improvement could be targeted by those involved in Touch such as individual associations at the direction of the sport's governing body.

The current state of concussion knowledge and attitudes in British American Football

OBJECTIVES

To examine concussion knowledge and concussion attitudes of players, coaches, and support staff in British American Football (BAF).

METHODS

Data from players, coaches and support staff (n = 236) were collected from across all leagues in BAF. An online survey tool was used which included the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS), and questions examining concussion education and perceived risk of participating in football.

RESULTS

The mean score on the RoCKAS concussion knowledge was 21.0 ± 2.1 of a possible score of 25 reflecting good knowledge. Of a possible score of 65, the mean concussion attitude score was 55.6 ± 6.1 showing safe attitude. Whilst an overall safe attitude was seen, almost half of participants (45.3%) noted they would continue to play with a concussion. No relationship was found between CAI and prior concussion history. Fifty seven percent of participants agreed the benefits of playing football outweighed the risks. Forty eight percent reported that they had received no concussion-related education in the past 12 months.

CONCLUSION

BAF participants have good concussion knowledge and safe attitudes. However, risky behavior is demonstrated through unsafe likelihood to report and attitude to long-term health risks. Access to the British American Football Association (BAFA) concussion policy and education was poor raising questions over what sources of information stakeholders are drawing their knowledge from. These findings can help form the foundation of educational interventions (e.g. coaching workshops) to challenge current misconceptions and improve likelihood to report concussion in BAF.

Effect of Hearing Status on Concussion Knowledge and Attitudes of Collegiate Athletes

CONTEXT

Collegiate athletes who are deaf or hard-of-hearing (D/HoH) are diagnosed with concussions at a similar rate as athletes who are hearing; however, little evidence exists on knowledge and attitudes of athletes who are D/HoH toward concussions. This study aimed to examine differences in knowledge of and attitudes toward concussions between athletes who are D/HoH and athletes who are hearing.

DESIGN

Cross-sectional research design.

METHODS

Of the 310 athletes who are D/HoH and 430 athletes who are hearing that were invited to participate, 90 athletes who are D/HoH, and 72 athletes who are hearing completed the survey. The Rosenbaum Concussion Knowledge and Attitudes Survey was used to quantify knowledge of and attitude toward concussions. The Rosenbaum Concussion Knowledge and Attitudes Survey consists of the concussion knowledge index (CKI) and the concussion attitudes index (CAI) subscales. Linear regressions were run to test the association of hearing status with CKI and CAI scores. Pearson correlations were performed to determine relationships between CKI and CAI for athletes who are D/HoH and athletes who are hearing. Alpha level was set a priori at P ≤ .05.

RESULTS

Athletes who are hearing demonstrated a higher CKI component score (19.58 [2.19]) compared to athletes who are D/HoH (16.14 [3.31]; P < .001). There were no statistical differences in CAI between hearing groups (hearing: 57.18 [8.73], D/HoH: 55.97 [9.92]; P = .41). There was a moderate positive correlation between CKI and CAI (r = .58) for athletes who are D/HoH, while a weak positive correlation (r = .30) for athletes who are hearing was observed.

CONCLUSIONS

Athletes who are D/HoH have poorer knowledge of concussions but similar attitudes toward concussion as that of athletes who are hearing. Current concussion educational interventions are in written or spoken form which may not be inclusive to athletes who are D/HoH. Health care professionals should consider an athlete's preferred communication mode to improve the efficiency and effectiveness of education.

Youth intentions to provide social support to a peer with a concussion

OBJECTIVES

1) To describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if demographic factors and concussion knowledge are associated with components of the Theory of Planned Behavior.

METHODS

The survey was completed between October 2018 and February 2019 by 200 youth (M = 15.30 years, SD = 1.52). Questions were designed for athletes and non-athletes and inquired about various types of social support. Data analysis included descriptive statistics, Wilcoxon Rank Sum Tests and Spearman's Rank-Order Correlation Coefficients.

RESULTS

More favorable attitudes and intentions to provide social support were observed among females (W = 2576, p ≤ 0.001; W = 2411, p ≤ 0.001), older youth (rho = 0.32, p ≤ 0.001; rho = 0.41, p ≤ 0.001) and those with higher concussion knowledge (rho = 0.29, p ≤ 0.001; rho = 0.22; p ≤ 0.001). Participating in sports with a high-risk of concussion was associated with lower attitudes and intentions to provide social support (W = 6677; p ≤ 0.001; W = 6721; p ≤ 0.001). Self-reported concussion history or knowing someone with a concussion history was not significantly associated with social support intentions.

CONCLUSION

This study identified characteristics of youth who had positive intentions to provide social support. These findings identify individuals who may model providing social support to a peer, as well as opportunities for future concussion education.

Development of a Measure of Parent Concussion Management Knowledge and Self-Efficacy

Abstract Assessing parent readiness to support their child's post-concussion management requires valid and reliable measures. Therefore, the objective of this study was to develop and conduct preliminary tests of reliability and validity of survey measures of parent concussion management knowledge and self-efficacy. Additionally, we tested the hypothesis that among parents of youth who had sustained a concussion, higher scores on measures of knowledge and self-efficacy would predict greater likelihood of engaging in recommended concussion management behaviors during their child's recovery. Measure development occurred with reference to parenting behaviors included in the Center for Disease Control and Prevention's Pediatric Mild Traumatic Brain Injury (mTBI) Management Guidelines. A multi-stage mixed- methods approach was employed, including expert review, cognitive interviews with parents, quantitative item reduction, and tests of reliability and validity. All participants were English-speaking parents of school-aged children in the United States. A stepwise measure development process was followed, with different participant groups across steps (including opt-in web-based survey panels and in-person recruitment from the population of parents of pediatric patients seen in a large pediatric emergency department). In total, 774 parents participated in study activities. The final knowledge index had 10 items, and the final self-efficacy scale had 13 items across four subscales (emotional support, rehabilitation support, monitoring, and external engagement). Internal consistency reliability was 0.63 for the knowledge index and 0.79-0.91 for self-efficacy sub-scales, and validation tests were in the hypothesized directions. In a test of predictive validity, we observed that among parents of youth patients with recent concussion, higher self-efficacy scores at the time of discharge from the pediatric emergency department were positively correlated (r = 0.12) with greater likelihood of engaging in recommended support behaviors at 2-week follow-up. There was no association between concussion management knowledge at discharge and parenting behaviors at follow-up. Parents have the potential to play an important role in concussion management. The measures of knowledge and self-efficacy developed in this study can help identify parent needs and evaluate interventions aiming to support parenting post-concussion.

Concussion injury management, perception, and knowledge in amateur field hockey

Background

Field hockey has a high risk for sports-related concussion (SRC) injuries due to the speed and intensity of the game, current rules, field surfaces and equipment composition. Head injuries are the second most common reported injury and up to 75% of SRCs go unreported or undetected. This increases the subsequent injury risk, long-term health consequences and prolonged injury recovery.

Objectives

This study aimed to examine the prevalence of SRC in hockey players within the Southern Gauteng Hockey Association (SGHA) premier league. Concussion knowledge and attitudes of hockey players, coaches, umpires, and officials were also investigated.

Methods

A partially mixed sequential dominant status design (QUANT-qual) was used, divided into two phases. In Phase One hockey players, coaches, umpires, and technical officials (n=119) completed a modified RoCKAS-ST questionnaire. In Phase Two, a focus group discussion with umpires (n=3) and interviews with coaches (n=3) were conducted.

Results

Injuries to the shoulder, neck, head, and face were reported from stick use (n=98); ball use (n=102) and collisions (n=187). Only 19% of hockey players were diagnosed with SRC, indicating that many of these injuries were undetected or not reported. Responses from the focus group discussion and interviews indicated that coaches, umpires, and officials felt they had insufficient knowledge of SRC.

Conclusion

The recognition and management of on-field injuries require improvement to enhance the injury detection system.

A psychometric evaluation of a new social subscale for the Common Misconceptions about Traumatic Brain Injury (CM-TBI) questionnaire: toward the CM-TBI-II

OBJECTIVE

Existing TBI misconception measures are critiqued for failing to measure postinjury social experiences. This study developed a social subscale for the Common Misconceptions about TBI (CM-TBI) questionnaire for use in the general public.

METHODS

Seven experts independently review items drawn from the literature. Shortlisted items were administered online to 158 adults (aged ≥18 years; 51% postschool educated; 60% no TBI experience), the CM-TBI, and a measure of construct validity (a published TBI-adaptation of the Community Attitudes Towards the Mentally Ill; CAMI-TBI). One week later, the new items were redeployed (n = 46).

RESULTS

Expert review and iterative correlations identified a 10-item social subscale (internal consistency, test-retest reliability, α's>.80). When added to the CM-TBI (ie. CM-TBI-II), the internal consistency was .71. The social subscale was significantly correlated with CAMI-TBI measures (p's <.05, r's > .3). There was no significant difference on the social subscale for education subgroups (school vs post-school, p = 0.056) or previous TBI experience; but there was a difference for the CM-TBI-II (post-school>school; Cohen's d = 7.83, large effect).

CONCLUSION

This study found strong preliminary psychometric support for a new social subscale, administered as the CM-TBI-II. This subscale shows promise as a measure of misconceptions about social functioning post-TBI. The CM-TBI-II could support evaluations of programs aiming to improve social engagement and community participation for people with TBI.

Concussion Knowledge and Self-Reported Behaviors in Youth Rugby Players and Their Coaches: A Population-Wide Cross-Sectional Survey

OBJECTIVE

To investigate concussion knowledge and self-reported behaviors in Italian youth rugby players and their coaches. To investigate predictors of lower concussion knowledge and association between athletes' self-reported knowledge and behavior.

DESIGN

Cross-sectional, population-wide, survey study.

SETTING

All rugby clubs (n = 52) of the Veneto region (Italy).

PARTICIPANTS

Players and coaches of all under 15, 17 and 19 teams. Overall, 1719 athlete surveys (92.2% male; response rate, 71.1%) and 235 coach surveys (93.6% male; response rate, 93.2%) were eligible for analysis.

INTERVENTION

Surveys circulated from September 20 to December 13, 2021.

MAIN OUTCOME MEASURES

Knowledge scores were reported as a percentage of correct answers. Descriptive statistics were reported for all answers. The primary outcomes were concussion knowledge and self-reported behaviors. The secondary outcomes were the association between knowledge and participant individual factors and self-reported behaviors.

RESULTS

Median knowledge score for athletes was 55% (IQR: 44-67) and for coaches was 60% (IQR: 52.5-69). Only 33.3% of athletes and 40% of coaches were aware of an increased risk of a second concussion after sustaining one. Athletes who had never heard of the word concussion (effect: -9.31; SE: 1.35, 95% CI: -12.0 to -6.7; P < 0.0001) and coaches with longer coaching experience (effect: -4.35; SE: 2.0, 95% CI: -8.29 to -0.41; P < 0.03) reported lower knowledge scores. There was no statistical association between knowledge scores and athlete self-reported behavior.

CONCLUSION

Athletes and coaches had a similar level of concussion knowledge. Knowledge score of athletes did not predict self-reported behaviors. Although enhanced concussion education should be undertaken, interventions to ensure appropriate concussion reporting behaviors are also required.

A cross-sectional study examining Nigerian footballers' knowledge and attitudes towards sport-related concussion and associated contextual factors

OBJECTIVE

To examine Nigerian footballers' knowledge and attitudes towards sport-related concussion (SRC) and associated contextual factors.

METHODS

A cross-sectional study design was used with an online questionnaire distributed to Nigerian footballers affiliated with a registered team. The questionnaire included demographic information and the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS-ST). The concussion knowledge index (CKI, 0-25) and attitude index (CAI, 15-75) were calculated. The association between various contextual factors with "high" knowledge and attitude were determined.

RESULTS

A total of 331 participants completed the questionnaire from 10 football clubs. Mean CKI and CAI scores were 14.0 ± 3.0 (56.2 ± 13.2%) and 54.5 ± 9.4 (72.6 ± 12.5%), respectively, and the association between scores was considered large (r = 0.530; 28%). A small proportion (n = 25; 7.6%) of participants reported a previous diagnosis of an SRC, with a further 40 (12.1%) suspecting they have suffered SRC. Thirty-five participants (10.6%) reported sustaining a SRC but did not seek medical help. Results indicated that men were at 4.8 times greater odds of having a "high[er]" CKI than women, and that those with 5-10 years playing experience had lower odds of a "high" CKI than those with >10 years' experience. Men had 7 times greater odds of having a "high" CAI than women.

CONCLUSION

The results of this study suggest that Nigerian footballers have a moderate level of SRC knowledge, satisfactory symptom recognition, and high SRC attitudes. Those working with Nigerian football may consider these findings when seeking strategies to improve concussion knowledge, potentially by improving attitudes and considering sex and playing experience.

Factors associated with concussion management behavior in Ladies Gaelic Football players

BACKGROUND

Sport-related concussion (SRC) management may be poor in community sports such as Ladies Gaelic Football (LGF). This study examined factors associated with SRC management behavior in adult LGF players.

METHODS

Participants (n = 657) answered an online survey on demographic factors, concussion knowledge, attitudes, and education, and SRC management behavior. Data from participants who reported sustaining an LGF-related SRC during the previous year (n = 115) were further analyzed.

RESULTS

Being diagnosed with SRC was the main factor influencing subacute management behavior. Players with diagnosed SRCs had increased odds of following a graded return-to-play (RTP) programme (OR = 4.89), following a medically supervised graded RTP programme (OR = 10.16), and being medically cleared before full RTP (OR = 13.45) compared with those with suspected SRCs. Concussion history was associated with increased odds of informing a coach of a possible SRC (OR = 2.86). Demographic factors, previous use of Ladies Gaelic Football Association concussion education resources, and concussion knowledge and attitudes had minimal or no influence on management behaviors.

CONCLUSION

Greater access to medical personnel at LGF training and matches is recommended. Due to limited medical resources in community sport, a clear referral pathway for players with SRC and comprehensive SRC education should be introduced to ensure players receive adequate medical care.

College students' perceptions of concussion: Illness beliefs and masculinity norms predict stigma and willingness to seek treatment

College students' beliefs and attitudes concerning concussion, and masculinity norms, were examined in relation to stigma and willingness to seek treatment for possible concussion. Beliefs were measured using a revised Illness Perception Questionnaire (IPQ). Participants: Participants were 631 undergraduates at a Northeastern university, most of whom were nonathletes with no concussion. Methods: Data were collected online. Regression analysis were performed to identify predictors of stigma and treatment willingness. Results: Beliefs that concussion symptoms reflect malingering, are controllable, and have psychological causes were related to more stigmatizing attitudes, as was endorsement of masculinity norms regarding winning and risk-taking. Believing that concussion symptoms are long-lasting and endorsing competitiveness, pain discounting, and self-reliance predicted willingness to seek treatment. Preliminary structural models showed adequate fit. Conclusions: In addition to beliefs assessed by the IPQ, traditional conceptions of masculinity warrant greater attention in the study of concussion-related stigma and willingness to seek treatment.

Investigation of concussion knowledge and attitudes of Chinese amateur adolescent soccer athletes

Concussions are a common traumatic brain injury in soccer games but are often ignored by coaches and athletes. The purpose of our study is to assess the concussion knowledge and attitudes among amateur adolescent soccer athletes in China. Data was collected from questionnaire surveying (Rosenbaum Concussion Knowledge and Attitudes Survey (Student Version)) and semi-structured interviews completed by 69 amateur adolescent soccer athletes who participated in the U17 and U15 male groups of the 2022 China Youth Soccer League. The study followed a mixed methodology cross sectional study design. The concussion knowledge index (0-25) and concussion attitude index (15-75) scores were derived from the questionnaire and descriptive statistics were used for data analysis. The mean score of concussion knowledge is 16.8 ± 2.4 (range 10-22), and the mean score of concussion attitude is 61.3 ± 8.8 (range 45-77). Thematic analysis was used to categorize the participant's responses of the semi-structured interview and the results were compared with their survey answers of questionnaire. Interestingly, the interviews revealed the inconsistencies between the questionnaire responses and intended behaviors, and multiple factors (injury severity, the importance of the game and substitution rules) influencing concussion-reporting behaviors were identified. In addition, athletes hope to acquire concussion knowledge through formal education. Our study lay the foundation for educational interventions to potentially improve concussion-reporting behaviors among amateur adolescent soccer athletes.

Concussion Education for Athletes: Symptom Reporting and Safe Return to Sport

» Educational programs on concussion have been demonstrated to improve knowledge for athletes, families, athletic trainers, and coaches about concussion, with the goal of reducing concussion incidence, duration, severity, and complications.» Despite the widespread availability and often mandatory concussion education provided to high school and collegiate athletes, there has not been an adequate change in knowledge, attitudes, and self-reporting behavior in this population.» Recently published studies suggest improving concussion education by emphasizing athletes' symptom reporting behavior, to contrast with current emphasis on knowledge-based outcomes.» Future educational programs about concussions for athletes, families, athletic trainers, and coaches should aim to emphasize cultural and behavioral changes that demonstrate outcome changes rather than solely evaluating knowledge improvements to determine effective programming.

Update on Pediatric Mild Traumatic Brain Injury in Rural and Underserved Regions: A Global Perspective

BACKGROUND

Mild traumatic brain injury (MTBI) causes morbidity and disability worldwide. Pediatric patients are uniquely vulnerable due to developmental and psychosocial factors. Reduced healthcare access in rural/underserved communities impair management and outcome. A knowledge update relevant to current gaps in care is critically needed to develop targeted solutions.

METHODS

The National Library of Medicine PubMed database was queried using comprehensive search terms (("mild traumatic brain injury" or "concussion") and ("rural" or "low-income" or "underserved") and ("pediatric" or "child/children")) in the title, abstract, and Medical Subject Headings through December 2022. Fifteen articles on rural/underserved pediatric MTBI/concussion not covered in prior reviews were examined and organized into four topical categories: epidemiology, care practices, socioeconomic factors, and telehealth.

RESULTS

Incidences are higher for Individuals in rural regions, minorities, and those aged 0-4 years compared to their counterparts, and are increasing over time. Rural healthcare utilization rates generally exceed urban rates, and favor emergency departments (vs. primary care) for initial injury assessment. Management guidelines require customization to resource-constrained settings for implementation and adoption. Decreased community recognition of the seriousness of injury is a consensus challenge to care provision by clinicians. Low parental education and income were correlated with decreased MTBI knowledge and worse outcome. Telehealth protocols for triage/consultation and rehabilitation were feasible in improving care delivery to rural and remote settings.

CONCLUSIONS

Pediatric MTBI/concussion patients in rural/underserved regions experience increased risks of injury, geographic and financial healthcare barriers, and poorer outcomes. Globally, under-reporting of injury has hindered epidemiological understanding. Ongoing MTBI education should be implemented for rural caregivers, schools, and low-income populations to improve community awareness. Telehealth can improve care delivery across acuity settings, and warrants judicious inclusion in triage and treatment protocols.

Sports fans, wagering, and concussion knowledge: implications for injury nondisclosure

OBJECTIVE

Athletes perceive sports fans as a source of concussion nondisclosure pressure. Sports fans are exposed to injury depictions from the media that could lead them to underestimate its seriousness. This study examined the concussion knowledge of non-sports fans, sports fans, and wagering sports fans, as knowledge is a modifiable factor that can influence injury disclosure.

SETTING AND PARTICIPANTS

A convenience sample of 443 Australian adults completed an online survey.

DESIGN

Cross-sectional.

MAIN MEASURES

Self-rated and actual concussion knowledge (the Rosenbaum Concussion Knowledge and Attitudes Survey; RoCKAS).

RESULTS

There was no significant difference in the concussion knowledge of self-identified sports (n = 157) and non-sports (n = 286) fans; but sports fans rated their knowledge as significantly higher than non-sports fans (p < .05). Wagering sports fans (n = 24) had significantly less concussion knowledge than non-wagering sports fans (η2 = .03, small effect).

DISCUSSION

Athletes who feel nondisclosure pressure from sports fans may be influenced by people with incomplete concussion knowledge, particularly wagering sports fans. Sports fans over-estimated their knowledge, and this could contribute to the nondisclosure pressure felt by athletes. Programmes to increase injury disclosure by athletes should take these factors into consideration.

Cross-Cultural Adaptation of the Urdu Version of Rosenbaum Concussion Knowledge and Attitude Survey—Student Version in Pakistan

Evaluating athletes’ knowledge of and attitudes toward sports-related concussions is important. However, there is limited research involving South Asian athletes, partly due to the lack of a valid and reliable tool. This study, therefore, aimed to translate and validate the Rosenbaum Concussion Knowledge and Attitude Survey—Student Version, an established tool used to measure knowledge and attitude toward concussion, into Urdu. Rosenbaum Concussion Knowledge and Attitude Survey—Student Version was translated into Urdu using the standard guidelines and then completed by 369 athletes participating in contact sports at different universities in Pakistan. Confirmatory factor analysis was performed on the Concussion Attitude Index items to examine the underlying factorial structure. Construct validity of Concussion Attitude Index factors was also investigated using convergent and discriminant validity. The results showed that the Urdu version of the Rosenbaum Concussion Knowledge and Attitude Survey—Student Version has good psychometric properties and is a valid and reliable tool for evaluating Urdu-speaking athletes’ knowledge of and attitudes toward concussions.

Research Letter: Concussion Knowledge Is Difficult to Predict From Self-Reported Exposure, Sports Participation, and Education

OBJECTIVES

Increasing concussion knowledge could contribute to improving injury outcomes. Understanding the predictors of concussion knowledge could determine the areas of educational need. This study examined whether individual factors, prior brain injury, prior concussion education, and contact-sports participation predicted concussion knowledge.

DESIGN AND SETTING

Cross-sectional study with recruitment of community volunteers.

PARTICIPANTS

An online survey was completed by 525 adults, 443 of whom provided useable responses.

MAIN MEASURES

The respondents provided background information and completed the Concussion Knowledge Index from the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS).

RESULTS

On average, the participants answered 19.8 out of 25 items correctly. A multiple regression model with demographic, injury, and sport-related variables did not significantly predict concussion knowledge.

CONCLUSION

This community sample had higher than expected concussion knowledge (restricted range), but some important misconceptions were still present. The model reflecting a combination of self-reported factors did not predict concussion knowledge. The implications for concussion education are discussed, including the need for targeted education to address specific misconceptions.

Parent-Child communication about concussion: what role can the Centers for Disease Control and Prevention's HEADS UP concussion in youth sports handouts play?

BACKGROUND

Concussion education for parents/guardians (hereafter referred to as parents) has the potential to play an important role in youth athlete concussion safety. The goal of this study was to evaluate the impact of the Centers for Disease Control and Prevention's (CDC) HEADS UP handout on parent-child communication about concussion.

METHODS

YMCA branches from 15 associations from across the United States were randomized to CDC HEADS UP intervention condition or education as usual control condition using a cluster randomization strategy. In the intervention condition, coaches shared parent- and athlete-specific handouts with parents and asked parents to share and discuss the athlete-specific handouts with their child. Generalized estimating equations, with repeated measures to account for the correlation among matched participants and YMCA associations, were employed.

RESULTS

Multivariable analyses exploring the relationship between time (pre- and post-intervention) and communication showed that the percent of parents who talked to their child about concussion increased in the intervention group (aRR=1.33, 95% CI=1.22, 1.44), but not in the control group.

CONCLUSION

CDC HEADS UP handouts help families talk about concussion safety. Sports organizations seeking to educate parents of athletes about concussion should consider using CDC HEADS UP handouts and following a similar dissemination strategy.

Parent influence on concussion reporting in first-year collegiate athletes

OBJECTIVE

To assess the relationship between sport-parenting practices and concussion reporting intentions of collegiate athletes across two levels of competition.

PARTICIPANTS

Entering first-year student-athletes (varsity and club) at a mid-sized university in the Southeast region of the United States (n = 327).

METHODS

Written surveys were completed prior to the start of the 2015 academic year. Structural equation modeling was used to test a model predicting concussion-reporting intentions.

RESULTS

College athletes were more likely to intend to report a suspected concussion when they believed their parents wanted them to report (B=-0.88, SD = 0.94), and when they experienced less sport achievement pressure from their parents (B=-0.12, SD = 8.07).

CONCLUSIONS

Parents influence the concussion safety of entering collegiate athletes at both the varsity and club level. Lower pressure sport parenting prior to college entry may help foster safer concussion reporting behaviors and may be an appropriate target for future intervention development work.

Postconcussion discharge advice does not improve concussion knowledge in a community sample

OBJECTIVE

Poor concussion knowledge in the community has been linked to reduced injury identification. This study investigated if concussion knowledge could be improved by providing standard postinjury advice (written brochure).

METHODS

This study was a prospective, controlled study, with random allocation of 199 Australian adults to receive either a concussion information (CI, n=101), or non-CI (n=98). All participants completed the Rosenbaum Concussion Knowledge and Attitudes Survey on three occasions: pre-education and posteducation, and 1 week later.

RESULTS

A 2 (condition) × 3 (occasion) mixed analysis of variance with concussion knowledge as the dependent variable did not find a statistically significant interaction (p>0.05). This result was unchanged: (1) with the covariate addition of background education and; (2) in a subgroup analysis (individuals with initially 'low' self-rated knowledge). Some key misconceptions about concussion were identified.

CONCLUSION

The community knowledge of concussion was not significantly improved by the concussion advice. Since injury recognition relies ton an extent on community knowledge, the identified misconceptions should be addressed. This could occur via public health messaging. In clinical settings and for future research, the next steps should also include regular updating of concussion information to keep pace with advances in the field.

Concussion Education in the School Setting: A Scoping Review

BACKGROUND

Concussions are a prevalent injury among youth, and concussion education has the potential to promote positive concussion-related behaviors. Recent recommendations and legislation have increased concussion education provided in schools; however, little is known about the education context, delivery method, development, and evaluation. A scoping review was conducted to identify peer-reviewed literature on concussion education delivered in the school setting.

METHODS

Six databases were searched (MEDLINE, CINAHL, EMBASE, PsycINFO, SPORTDiscus, and ERIC) to identify published articles from 2002 to July 16, 2020 that delivered concussion education in the school setting. Included studies described the concussion education and were written in English.

RESULTS

A total of 11,373 articles were identified and screened, with 27 studies meeting eligibility criteria and therefore, included. The studies delivered education to various stakeholders including students (n = 12; 44.4%), coaches (n = 5; 18.5%), educators (n = 3; 11.1%), parents (n = 1; 3.7%), and a mixed audience (n = 6; 22.2%). The education format varied and six studies (22.2%) developed the education based on a theory, model, or framework.

CONCLUSIONS

This study found substantial variability in the context, delivery method, development, and evaluation of education delivered in schools and further evaluation of this education is needed to ensure it is best-suited for school-based stakeholders.

Knowledge of, and Attitudes Toward, Concussion in Japanese Male Collegiate Athletes

Japan has no streamlined concussion education for collegiate athletes, and guidelines vary by sport. In particular, research on knowledge of, and attitudes toward, concussion is necessary for the establishment of concussion education for Japanese collegiate athletes. The aim of the present study was to assess the knowledge of, and attitudes toward, concussion in Japanese male collegiate athletes and to investigate their experiences with suspected concussion symptoms. An online questionnaire was administered to 390 collegiate athletes participating in the following five sports with a high incidence of concussion: rugby union, soccer, basketball, American football, and judo. Of the 121 valid responses, 91 (77.1%) indicated that they had experienced suspected concussion symptoms at least once and 46 of these 91 respondents had not reported their symptoms of suspected concussion at least once. Athletes who had never experienced concussion symptoms were significantly less likely to recognize the symptoms of concussion (p &lt; 0.001). Most athletes recognized headache and dizziness as suspected concussion symptoms. However, the recognition rate for several symptoms was lower than the prevalence of these symptoms as shown in previous studies. This suggests that educational initiatives might be important to bridge the gap between athletes' knowledge and understanding of frequently occurring concussion symptoms and to improve reporting behavior.

Effects of a faculty training program on knowledge and awareness of student concussion and academic performance

Objective The purpose of this pilot study was to determine the feasibility of implementing a concussion educational program to college faculty and to explore the effect of the program on faculty knowledge regarding concussion and the effect on learning and return to school. Methods: The study utilized a mixed method design, with a pretest and post-test to measure concussion knowledge before and after a didactic presentation on concussion and academic performance. Semi-structured interviews gathered information on faculty's perception of concussion and academic performance. Results: Faculty demonstrated improved scores on post-test knowledge assessment of concussion and academic performance. Faculty reported that they would be more likely to observe for signs of concussion in students, and would be more willing to adhere to recommendations for academic accommodations. Conclusions: The results of the study indicate that a didactic presentation on concussion and academics may be a feasible method for training college faculty.

Evaluating Adult Decision-Making Modifiers in Support of Youth Contact-Sport Participation

CONTEXT

Nearly 44 million youth participate in organized youth sports programs in the United States each year. However, approximately 25% of parents have considered removing their children from sports due to the fear of concussion.

OBJECTIVE

To determine which adult decision-making modifiers (eg, gender, educational attainment, career type) influenced support for youth contact-sports participation.

DESIGN

Cross-sectional study.

SETTING

Midwestern university and medical center.

PATIENTS OR OTHER PARTICIPANTS

Convenience sample of staff and faculty (N = 5761; 73.9% female) from 2017 to 2018.

MAIN OUTCOME MEASURE(S)

Support for youth contact-sports participation using multivariate binary logistic regression to calculate odds ratios and 95% CIs.

RESULTS

The sample was split between adults with children (AWCs; n = 3465, age = 45.39 ± 13.27 years, 76.72% female) and adults without children (AWOCs; n = 2296, age = 30.84 ± 9.01 years, 70.26% female). Among AWCs, those who obtained a bachelor's degree or higher were more likely to support contact-sports participation. Females were more inclined to allow all contact sports, specifically football (odds ratio [OR] = 2.22; 95% CI = 1.64, 3.01) and ice hockey (OR = 1.98; 95% CI = 1.42, 2.78). Overall, previous adult sport participation, increasing number of children, and child gender were significant modifying variables in greater support of youth contact-sports participation among AWCs (P < .001). Among AWOCs, previous sport participation in football (OR = 3.27; 95% CI = 2.14, 4.87), ice hockey (OR = 4.26; 95% CI = 2.23, 8.17), or soccer (OR = 2.29; 95% CI = 1.48, 3.54) increased the likelihood of an adult supporting contact-sports participation. Lastly, all adults were less inclined to support a daughter participating in any contact sport than a son.

CONCLUSIONS

These results reveal adult- and child-specific variables that may influence youth contact-sports participation. These decisions may be developed through the lens of certain gender role beliefs and may lead adults to perceive certain sports as more appropriate for sons than daughters.

United States Air Force Academy Cadets' Unprompted Knowledge of Concussions and "Bell Ringers" or "Dings": Perceived Differences and Similarities

CONTEXT

After a possible concussion mechanism, cadets are unlikely to have a list of concussion signs and symptoms at their disposal. As such, unprompted concussion knowledge may be an essential factor in personal recognition of injury.

OBJECTIVE

To explore determinants that contributed to United States Air Force Academy (USAFA) cadets' disclosure of a concussion. This research focused on 1 of 8 overall discovered themes of unprompted concussion knowledge.

DESIGN

Qualitative study.

SETTING

Military academy.

PATIENTS OR OTHER PARTICIPANTS

Cadets at the USAFA (males = 23, females = 11, age = 19.91 ± 1.14 years).

MAIN OUTCOME MEASURE(S)

We conducted 34 semistructured interviews. The transcribed text was analyzed in a 5-cycle process. From this process, 8 overall themes emerged, including unprompted concussion knowledge. Subthemes were concussion definition, concussion symptoms, "bell-ringer" or "ding" definition, "bell-ringer" or "ding" symptoms, and concussion versus "bell ringer" or "ding."

RESULTS

Many participants were able to describe a concussion fairly accurately. The most commonly listed concussion signs and symptoms were dizziness (n = 22/34, 64.7%); "can't remember"/"memory loss"/"forgetful" (n = 19/34, 55.9%); and headache (n = 16/34, 47.1%). The cadet participants characterized the most common bell-ringer or ding signs and symptoms as dizziness (n = 2/34, 5.9%) and headache (n = 2/34, 5.9%). Cadets also described how a bell ringer or ding differs from a concussion, often commenting that concussions were more severe than bell ringers or dings.

CONCLUSIONS

Overall, USAFA cadet participants listed common concussion signs and symptoms. However, they perceived differences between a concussion and a bell ringer or ding. Although decreasing the use of colloquial terms for concussion is recommended, use of these terms when examining a concussion history may be helpful. Concussion-education interventions should continue to focus on describing concussion signs and symptoms using cadets' own words to describe the injury (eg, "forgetful") but differentiating between what may and may not be a concussion and encouraging individuals to consult health care providers regarding possible concussion symptoms.

Concussion Knowledge and Attitudes in Reserve Officers' Training Corps Cadets

INTRODUCTION

Military members' knowledge of concussion signs and symptoms may be critical to appropriate concussion identification and health-seeking behavior, particularly for those in leadership roles. The current study aimed to characterize concussion knowledge and attitudes among future military officers undergoing U.S.-based Reserve Officers' Training Corps (ROTC) training.

MATERIALS AND METHODS

Army and Air Force ROTC cadets at 2 large, public universities were utilized for a survey-based observational study. The study was approved by the institutional review board at both university research sites. Cadets completed a modified Rosenbaum Concussion Knowledge and Attitude Survey to obtain cadets' Concussion Knowledge Index and Concussion Attitude Index, where higher scores are preferable. Cadets' concussion knowledge and attitudes were characterized via descriptive statistics.

RESULTS

Cadets (n = 110) had a mean Concussion Knowledge Index of 18.8 ± 3.2 (range = 9-23, out of 25). Potentially detrimental misconceptions included: belief that typically concussion symptoms no longer persist after 10 days (79.1%) and brain imaging shows visible physical damage following concussion (74.5%). Mean Concussion Attitude Index was 60.6 ± 7.4 (range = 46-75, out of 75). In general, cadets reported higher agreement with safe concussion behavior than what they believe peers would report.

CONCLUSIONS

Cadets were found to have a high concussion knowledge, yet common misconceptions remained. Cadets consistently reported safe choices but were less sure that peers felt similarly; future investigations should evaluate ROTC concussion social norms and education should note peers' beliefs supporting safe concussion attitudes.

Parent knowledge of and attitudes towards youth sport-related concussion and associations with child and parent factors

Aim:

This cross-sectional study aimed to better understand parental knowledge and attitudes regarding pediatric sport-related concussions, and association with parent/child biopsychosocial factors.

Methods:

A community sample of ninety families (n = 140 children) were included. Parental concussion knowledge and attitudes, concussion history, sport participation and social risk status score (SRS) were collected.

Results:

Parents scored an average of 76% accuracy on factual concussion knowledge, with 74% confidence in responses. Parents endorsed a favorable attitude toward concussion reporting and management. Low SRS had higher perceived accuracy of knowledge than medium or high SRS (p = 0.003). SRS influenced over-and-underestimations of factual knowledge (p = .04). Age at first sport and sport contact level influenced factual and perceived concussion knowledge.

Conclusion:

These findings identify common gaps in concussion knowledge in parents.

Investigating Concussion Knowledge in US Born Versus Internationally Born Collegiate Student-Athletes in the United States

OBJECTIVE

To compare concussion knowledge between US born and internationally born collegiate student-athletes. Furthermore, to investigate whether length of time in the United States impacted concussion knowledge.

DESIGN

Survey.

SETTING

Preparticipation physicals at a midwestern NAIA college.

PARTICIPANTS

Three hundred one collegiate student-athletes.

INTERVENTIONS

Demographic questionnaire and the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS).

MAIN OUTCOME MEASURES

t test was used to determine whether a difference in Concussion Knowledge Index (CKI) scores exists between US born and internationally born student-athletes. A one-way analysis of variance was used to determine significance for length of time in the United States.

RESULTS

A statistically significant difference was found for CKI scores between US born (19.22 ± 2.38) and internationally born student-athletes (18.01 ± 2.57) (t = 3.895, P = 0.000). Analysis of variance demonstrated statistically significant difference for CKI scores (F2,300 = 13.883, P = 0.001). Post hoc analysis found significant differences in CKI scores between US born (19.22 ± 2.38) and internationally born student-athletes in the United States less than 2 years (17.31 ± 2.52) (P = 0.000), and between internationally born student-athletes in the United States 2 or more years (19.15 ± 2.25) and internationally born student-athletes in the United States less than 2 years (17.31 ± 2.52) (P = 0.002).

CONCLUSION

Among this sample, being born in the United States and length of time in the United States contribute to student-athletes' concussion knowledge.

CLINICAL RELEVANCE

Standardized guidelines are needed to assist health care professionals in properly educating student-athletes about concussions as the recognition and management of concussions can be affected by a student-athlete's knowledge.

Can Adults Recognize Concussion Symptoms? A Critical Review of Empirical Research Using the Rosenbaum Concussion Knowledge and Attitudes Survey

OBJECTIVE

The correct identification of concussion symptoms is vital for mild traumatic brain injury recognition, diagnosis, and injury management. Numerous surveys of symptom recognition have been conducted, including with athletes at-risk for injury. This critical, methodologically focused review aimed to: (1) discover which concussion symptoms are recognized, and (2) provide recommendations for future research.

DATA SOURCES

A quasi-systematic literature search was conducted to identify studies that used the Rosenbaum Concussion Knowledge and Attitudes Survey.

STUDY SELECTION

Eighty-five publications were identified, 8 of which were retained after screening.

DATA EXTRACTION

The identification of individual concussion symptoms was coded as good (a correct response by >90% of the sample), moderate (a correct response by 75%-90% of the sample), or poor (a correct response by <75% of the sample).

DATA SYNTHESIS

The pooled data comprised responses from more than 2000 individuals, most of whom were male, young adult, sport players. Overall, there was good recognition of 3 concussion symptoms (headaches, dizziness, and confusion), poor recognition of sleep disturbances, nausea, and loss of consciousness, and misattribution to concussion of 2 distractor symptoms (weakness of neck range of motion, difficulty speaking). The methodological evaluation revealed significant variability in symptom measurement.

CONCLUSIONS

The identified trends for concussion symptom recognition must be regarded as tentative because of the significant methodological variation in the reviewed studies. This variability affected the number, wording, and classification of items, and it restricted the data synthesis. This problem must be addressed in future research and recommendations are provided.

Level of knowledge and misconceptions about brain concussion in Brazilian adults

BACKGROUND

Brain concussion (BC) is seen as a public health priority due to its high incidence and morbidity rate, among thousands of people around the world. There are needs for fast identification, accurate diagnosis and correct management in order to reduce the short and long-term problems relating to BC. Proper knowledge of BC in the population and among clinicians is a critical factor in achieving this.

OBJECTIVES

To evaluate the level of self-reported BC knowledge and gaps/misconceptions, and to identify variables correlated with this level.

METHODS

A cross-sectional descriptive survey was performed. A Brain Concussion Knowledge Questionnaire (BCKQ) that had been created to capture data was widely distributed. Total scores, domain partial scores and percentages of correct and incorrect answers were calculated to ascertain the level of knowledge relating to BC.

RESULTS

The sample was formed by 1,247 Brazilian adults (age: 41.7±11.8 years). Partial scores of the BCKQ revealed the existence of poor knowledge and misconceptions in all domains of the questionnaire, especially regarding questions about recovery from and management of BC. Moderate correlations between BCKQ scores and professions (p=0.312; P=0.00) or previous brain concussion knowledge (p=0.489; P=0.00) were observed. In a multiple linear regression model, age, profession and sports practice were predictors of BC knowledge.

CONCLUSION

This first study to analyze the level of BC knowledge in a sample of Brazilian adults suggests that poor knowledge and misconceptions are present. Thus, meaningful and useful information was provided by this study for developing health education programs about BC for the population in order to improve fast diagnosis and correct BC management.

Blowing the Whistle on Concussion Knowledge and Education in Youth Sport Referees

Purpose

To gain an understanding of referee concussion knowledge, what sporting organizations were doing to prepare their referees to recognize concussions in youth sport, and what role referees could play in overall concussion safety.

Materials and Methods

A total of 134 referees participated in the study across four provincial sporting organizations (rugby, soccer, ice hockey, and football). Participants completed a concussion knowledge questionnaire that explored knowledge about concussion education, recognition, management, preparedness, and the role of the referee in overall concussion management.

Results

Overall, the sample was found to be moderately knowledgeable about concussions. Referees that received previous formal concussion education had statistically significant higher average scores when compared to those without formalized concussion education (P=0.001). However, only 24% of respondents reported receiving any formal education from their sporting body or referee organization. About 85% felt that referees could play an important role in concussion recognition in youth sport, but only 41% felt they were adequately equipped with the knowledge and skills to recognize these injuries.

Conclusion

The findings from this study suggest that national, provincial, and individual sporting organizations should ensure that all stakeholders (including referees) are formally educated about concussions to encourage a safety-first environment for youth athletes. Educational sessions should focus on the general aspects of SRC while also focusing on the specific role of the referee in concussion recognition.

Psychometric properties of concussion knowledge and cognitive mediators of reporting measures

Context: Concussion education and prevention programs require reliable and valid instruments to evaluate the theory, mechanisms, and outcome of these interventions Objective: To assess the psychometric properties of measures evaluating concussion education and prevention programsDesign: Descriptive epidemiological Setting: 10 NCAA-member universities Patients or Other Participants: 841 student-athletes in an RCT control group testing an ecological, peer-led concussion education program Main Outcome Measures: Instruments adapted for assessing concussion knowledge and Theory of Planned Behavior/Theory of Reasoned Action (TPB/TRA) cognitive mediators of reporting behavior (attitudes, subjective norms, perceived control, and intentions to report concussion). Participants completed measures at baseline, after one hour, and after one month Results: Internal consistency and test-retest reliability were moderate for both the concussion knowledge and cognitive mediator measures. TPB/TRA was supported subscale intercorrelation and item factor analysis in the cognitive mediator scale. Factor analysis of the concussion knowledge measure revealed subscales for physical/cognitive, psychological/affective, and non-symptoms. The intermediate TPB/TRA mediators of attitudes, norms, and perceived control predicted greater intention-to-report, which predicted increased likelihood of reporting concussion one month later.Conclusions: Measures of concussion knowledge and cognitive mediators of reporting adapted from the literature show adequate psychometric properties and support TPB/TRA application for concussion reporting behaviors.

A Concussion Education Programme for Motorsport Drivers: A Field-Based Exploratory Pilot Study

OBJECTIVE

Concussion education strategies that improve knowledge and attitudes long term are needed. This exploratory study piloted an interactive concussion education program, adopting concepts from the learning sciences and attitude change literature, for the underserved and high-risk population of motorsports.

METHOD

Forty UK motorsport drivers (ages 16-20 years) participated. The workshop group received a two-phased workshop-based program. The comparison group received a concussion leaflet. Participants completed an adapted version of the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS-ST) at pre-, post- and 2-month follow-up. Within-group analysis for the workshop group explored the differential effect of the individual difference variable, Need for Cognition (NfC), and effectiveness was explored through post-workshop questionnaires and interviews.

RESULTS

Unlike the comparison group, the workshop group showed a significant improvement in knowledge over time (F(2,58) = 45.49, p < .001, ^η2p = .61). Qualitative data indicated workshop-program participants developed safer attitudes toward concussion following programming. Preliminary evidence suggested individuals' responses to concussion education aligned with differences in NfC.

CONCLUSION

This study piloted the first concussion education program for motorsport drivers and explored whether aligning educational provision with the NfC construct may help to improve program effectiveness. Findings are relevant to addressing the public health issue of concussion through educational approaches.

In it to win it: Competitiveness, concussion knowledge and nondisclosure in athletes

OBJECTIVES

Despite having a general understanding of concussions, many athletes choose not to report symptoms of a sports-related concussion (SRC) which leads to a larger burden on our healthcare system due to longer recoveries, more Emergency Department visits, and future medical appointments. Thus, there is a need to identify factors, such as competitiveness, that may help to better explain the nondisclosure of concussion symptoms. The current study aimed to investigate the role of athletes' concussion knowledge and competitiveness on concussion nondisclosure.

METHODS

Participants included 161 Canadian athletes (ages 14-32; 71% male) participating in collision sports (American football, rugby, hockey), soccer or rowing. Concussion knowledge, reporting and competitiveness were measured using the Rosenbaum Concussion Attitude and Knowledge Survey and Sports Orientation Questionnaire (SOQ). Two logistic regression models were performed to explain both history and future intention of playing despite experiencing concussion symptoms.

RESULTS

Age, sex, and concussion knowledge were not significant for the regression models. The SOQ scores (measuring competitiveness) were significant for both regression models, such that higher competitiveness was associated with increased likelihood for past nondisclosure (b =.03, p =.03, OR = 1.03 (97.5% CI: 1.003,1.06)) and future nondisclosure intention (b =.05, p =.00, OR = 1.05 (97.5% CI: 1.03,1.08)). Regarding concussion knowledge, soccer players had significantly higher knowledge than those in collision sports and rugby, F(2, 158) = 140.5, p =.00; female athletes had significantly higher knowledge than males, t(66) = -4.26, p =.00; age was negatively associated with concussion knowledge (r = -0.35, p < .01).

CONCLUSION

The results suggest that healthcare providers should be aware that athletes tend to have adequate concussion knowledge, but this knowledge does not explain past nondisclosure or future nondisclosure intention. Based on these findings, healthcare providers should focus on being able to identify highly competitive athletes who are most at risk of nondisclosure instead of exclusively aiming to increase concussion knowledge in athletes.

Effectiveness of PitchSafe on Knowledge and Attitude of Baseball-Related Concussion

Background

Traumatic brain injuries (TBIs), specifically concussions, affect many athletes and have dangerous immediate and long-term sequelae. Lack of awareness surrounding concussion impedes prevention, identification, and treatment. This study aims to assess parental knowledge and attitudes regarding concussions in youth baseball before and after administering an educational intervention called PitchSafe. PitchSafe is a short video that contains examples of baseball-related head injuries such as collisions, falls, and direct hits by baseballs; the signs and symptoms of a concussion; testimony from a former baseball player who sustained a TBI playing baseball; and a brochure detailing the potential signs, symptoms, and treatment plans associated with concussions.

Methodology

The Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) was used to assess three indices of parental understanding of concussion: Concussion Knowledge Index (CKI), Concussion Attitudes Index (CAI), and signs and symptoms of concussions (SS). The RoCKAS was administered at baseline and after the PitchSafe tool was administered. Parents were re-assessed one year following the initial distribution of survey materials utilizing the long-term follow-up (LTFU) RoCKAS. A paired sample t-test was conducted to compare the baseline, post-intervention (PI), and LTFU CKI, CAI, and SS among participants.

Results

The mean scores for CKI were 68% ± 12%, 76% ± 4%, and 76% ± 5% for baseline, PI, and LTFU, respectively. The mean scores for SS were 46% ± 20%, 62% ± 14%, and 64% ± 16% for baseline, PI, and LTFU, respectively. The mean scores for CAI were 87% ± 6%, 91% ± 5%, and 92% ± 4% for baseline, PI, and LTFU, respectively.

Conclusions

PitchSafe increased youth baseball parents’ long-term knowledge of concussions, ability to identify signs and symptoms of concussions, and may promote safer attitudes toward concussions. These findings support more widespread use of educational tools through social media and in clinical settings.

Student Perspectives on the Role of Peer Support Following Concussion: Development of the SUCCESS Peer Mentoring Program

Purpose College students with concussion are often ill-equipped to manage their health and learning needs, and college campuses are slow to react. We present the development of a peer mentoring program for college students with concussion: Success in College after Concussion with Effective Student Supports (SUCCESS), focusing on the process by which student needs and preferences drove development of the program for testing. Method Principles of person-centered design were used to guide program development, engaging stakeholders at each stage of development and resulting in the intervention package presented to student participants here. A series of interviews and focus groups with 11 students with concussion addressed student needs after concussion, student perceptions of the role of peers in recovery, and feedback on program development. Results Findings indicate students have limited knowledge about concussion, and concussion impacts extend beyond school, although students are most concerned about their studies. Students reported struggling to communicate with professors and find resources on campus to aid in their reentry to learning. Regarding peer mentoring, students report benefiting from hearing about other's successes and sharing personal narratives of injury and recovery. Students reported high acceptability of a peer mentoring program, both for psychosocial support and access to resources. Conclusions College students with concussion have unmet needs as they return to learn. The SUCCESS peer mentoring program is highly acceptable to students, who report that they would expect such a program to be engaging and to meet their needs. The program's impact on student academic and psychosocial outcomes should be investigated through comparative efficacy trials.

Baseline Concussion Testing Increases Agreement With Favorable Concussion Safety Decisions in Hypothetical Scenarios

BACKGROUND

Dangers of sports-related concussion are well documented, and those participating in sports involving significant contact are at an even higher risk relative to the general population. Despite extensive concussion education, athletes still make decisions that would be considered unsafe, such as underreporting and continuing to play despite experiencing symptoms. Although baseline testing is an increasingly common practice at all levels of sport, little is known about its ability to improve player safety perceptions.

AIMS

The current study examines whether taking part in a standardized baseline concussion assessment changes athletes' knowledge, attitudes, or perceptions of concussion safety decisions.

METHOD

A total of 229 club and National Collegiate Athletic Association athletes completed a modified Rosenbaum Concussion Knowledge and Attitudes Survey-Student Version (RoCKAS-ST), which was used to evaluate knowledge, attitudes, and perceptions of concussion safety decisions in hypothetical scenarios. Athletes were randomly assigned to either complete baseline concussion testing prior to the RoCKAS-ST or complete baseline testing after the RoCKAS-ST.

RESULTS

Athletes randomly assigned to complete baseline testing before the RoCKAS-ST demonstrated greater agreement with favorable concussion safety decisions in hypothetical scenarios relative to athletes completing baseline testing after the RoCKAS-ST. The two conditions did not differ with respect to concussion knowledge or attitudes.

DISCUSSION

Baseline testing appears to have an added benefit of resulting in more favorable perceptions toward making safe decisions following suspected concussions.

CONCLUSION

Baseline testing may provide an effective means of improving a broader constellation of concussion safety behavior, particularly in club athletes, who are typically underserved in terms of concussion-related resources and care.

Concussion-reporting behaviors among high school athletes in Ireland: Applying the theory of planned behavior

Background

Sport-related concussion is a significant public health issue, especially among children and adolescents. A growing body of evidence suggests that athletes who do not immediately report concussion and continue to play while concussed take longer to recover than their counterparts. Yet, many child and adolescent athletes do not immediately report concussion symptoms to a responsible adult.

Aim

This study examined the utility of the Theory of Planned Behavior (TPB) in predicting concussion reporting intentions and in-season reporting behaviors among high school, Gaelic Athletic Association (GAA) athletes in the Republic of Ireland.

Methods

High school GAA athletes aged 12-18 years completed surveys at baseline and at three-month follow-up. Concussion-related perceived behavioral control (PBC), attitudes, subjective norms, and reporting intentions were assessed at baseline. In-season concussion reporting behaviors were assessed at three-month follow-up. Hierarchical linear regression models were used to examine the relationship between the constructs of the TPB and baseline reporting intentions. Logistic regression models were used to examine the relationship between the constructs of the TPB and in-season reporting behaviors. All data were collected during the 2016–2017 academic year.

Results

A total of 153 adolescent athletes were included (n = 102 [66.7%] females; Mage = 14.4 years, [SD = 1.6]). Consistent with the TPB, results revealed that PBC and reporting intentions contributed to the prediction of in-season reporting behaviors. Reporting intentions, in turn, were strongly influenced by PBC, attitudes, and subjective norms. PBC was the strongest predictor of concussion reporting intentions and in-season reporting behaviors; the stronger the athletes’ PBC, the stronger their reporting intentions and the more likely they were to have reported concussion symptoms during the current season.

Conclusion

Although the findings from the current study must be interpreted cautiously given the small sample size, the findings suggest that the TPB has some utility in the prediction of concussion reporting intentions and reporting behaviors. However, our findings suggest that the TPB should not be used in isolation; other models that incorporate personal factors and environmental constraints may be needed to better our understanding of concussion reporting intentions and behaviors among high school athletes. Concussion education programs that include strategies to enhance PBC over concussion reporting may help improve concussion reporting behaviors among high school athletes.

Evaluating the Effect of Concussion Education Programs on Intent to Report Concussion in High School Football

CONTEXT

Concussion underreporting leads to delays in diagnosis and treatment, prolonging recovery time. Athletes' self-report of concussion symptoms therefore reduces risk.

OBJECTIVE

Evaluate the efficacy of three concussion education programs in improving concussion-reporting intention.

DESIGN

Randomized controlled clinical trial with assessment immediately and one-month after education.

SETTING

Three high schools in California.

PATIENTS OR OTHER PARTICIPANTS

118 male football players were randomly assigned to receive concussion education via: CrashCourse (CC), Centers for Disease Control (CDC) video educational materials (Vi), or CDC written educational materials (Wr).

MAIN OUTCOME MEASURES

Concussion-reporting intention was assessed at baseline, immediately after education, and at one-month follow-up. Secondary outcomes included concussion knowledge, attitudes, perceived reporting norms, and perceived behavioral control.

RESULTS

Athletes across all educational formats had significant improvement in concussion-reporting intention immediately following education and at one-month follow-up (mean improvement 6.8% and 11.4%, respectively; p<0.001). Similar findings were observed across all education formats in secondary analyses examining knowledge, attitudes, and perceived behavioral control. However, there were significant differences by education and time (p=0.03). On post-hoc analysis, athletes who received CC had increased concussion-reporting intention immediately and at one-month (baseline=4.7, immediate=6.1, one-month=6.0; p=0.007 compared to significant increases only at one-month for CDC-Vi (baseline=4.3, immediate=5.2, one-month=5.8; p=0.001), and no significant improvement for CDC-Wr (p=0.10). Secondary analyses indicated significant differences between CC and both CDC interventions, in concussion knowledge and attitudes, immediately after education and at one-month. There were no significant differences in perceived behavioral control between-interventions or in perceived concussion-reporting norms across or between interventions.

CONCLUSION

All athletes exhibited improved intent to report concussions, increased concussion knowledge, better concussion attitudes, and more perceived behavioral control, both immediately after education and at one-month follow-up. However, athletes randomized to CC reported greater intent to report concussion, more knowledge, and improved concussion-reporting attitudes, when compared to CDC-Vi and CDC-Wr.

TRIAL REGISTRY

ClinicalTrials.gov trial ID number is XXX.

Understanding concussion knowledge and behavior among mixed martial arts, boxing, kickboxing, and Muay Thai athletes and coaches

Objectives: In combat sports, strikes to the head are not just incidental but a deliberate and clear determinant of success. Concussion is a complex injury that is poorly understood and inappropriate practices are often observed among athletes and coaches. The purpose of this study was to investigate concussion knowledge and behavior as well as address recommendations for combat sports athletes and coaches. Methods: 70 athletes and 35 coaches from combat sports disciplines completed an online-validated survey and a personal questionnaire about concussion knowledge, training experience, and knowledge translation. Athletes were divided into subgroups for analysis according to sex (male n = 55, female n = 15), skill level (amateur n = 52, professional n = 18), and weight classes (<66.2 kg: n = 25, 66.6 to 77.5 kg: n = 30, and >78 kg: n = 15). Results: The likely absence of health-care professionals during training was confirmed by 68.5% of coaches, and athletes declared that self-diagnosis (79%) and coaches' diagnosis (43.3%) were the most used method of suspected concussion assessment. Merely 5.7% of coaches properly recognized the level of traumatic brain injury a concussion represents, 68.8% were unfamiliar with any sideline assessment tools, and only 14.3% often seek out concussion knowledge. Athletes who were aware of the level of brain injury a concussion represents performed fewer sparring sessions per week (mild: 1.27 ± 1.1; severe: 3.17 ± 2.81; p = .05, d = .89) and had a greater likelihood of reporting concussive episodes. Most professional (55.5%), female (54.5%), and under 66.2 kg (50%) athletes returned to full practice within 1 week following a concussion diagnosis. Conclusions: Relevant key gaps of knowledge and behavior were verified in combat sports athletes and coaches. The awareness of basic concepts may improve injury reporting and safer behavior in athletes. Knowledge translation strategies with accessible language are recommended for coaches, in particular on how to identify acute symptoms and perform basic assessment.

Concussion in Motorsport? Experience, Knowledge, Attitudes, and Priorities of Medical Personnel and Drivers

OBJECTIVE

To assess concussion experiences, knowledge, and attitudes of motorsport medical personnel and drivers and to determine priority areas regarding concussion within the sport.

DESIGN

Sequential mixed-method design. Part 1: stakeholder interviews; part 2: cross-sectional online survey.

SETTING

United Kingdom.

PARTICIPANTS

Part 1: key motorsport stakeholders (N = 8); part 2: motorsport medical personnel and drivers (N = 209) representing amateur and/or professional 4-wheeled motorsport.

MAIN OUTCOME MEASURES

Concussion experience, knowledge, attitudes, and perceived priority areas.

RESULTS

Thirty-one percent of surveyed drivers (age = 37.91 ± 13.49 years: 89% male) reported suffering from concussion in motorsport. Eighty-seven percent of surveyed medical personnel (age = 48.60 ± 10.68 years: 74% male) reported experience with concussed drivers, and 34% reported feeling pressured to clear a driver with concussion. Gaps in knowledge and misperceptions about concussion were reported in both groups, and disparity between concussion attitudes emerged between drivers and medical personnel. Application of assessment and management procedures varied between medical personnel and there was evidence motorsport policy and concussion guidelines may not be directly followed. According to both medical personnel (77%) and drivers (85%), "education and training" is the top priority area for the sport.

CONCLUSIONS

There is clear evidence of concussions in motorsport, but accurate knowledge about this injury is missing. Concussion education and training for all drivers and medical personnel is required. Additional investigations into concussion attitudes are advised to complement and advance simple educational initiatives. Further investigation is also required to determine how to best support motorsport medical personnel, and general practitioners, who hold significant responsibility in guiding drivers from diagnosis to return to racing, and to support the effective implementation of policy.

A systematic review of the effects of educational interventions on knowledge and attitudes towards concussion for people involved in sport - Optimising concussion education based on current literature

Educational interventions aimed at increasing concussion knowledge and attitudes are designed according to different frameworks. The aim of this systematic review of the literature was to determine the effects of educational interventions on concussion knowledge and attitudes, while providing recommendations for future research in the area of concussion education interventions. Data were extracted from 25 papers following a systematic search of the CINAHL, PubMed/Medline, Science Direct, SPORTDiscus and Web of Science scientific databases. Interventions were designed according to expert opinion and recommendations from previous research, such as knowledge transfer frameworks, the Health Belief Model, Theory of Planned Behaviour or by unknown means. Interventions were presented using PowerPoint presentations, videos, interactive computer modules, tool-kits, games and as guidelines. Interventions designed according to expert opinion increased concussion knowledge during post-intervention testing up to 2 weeks after intervention administration, and occasionally increased attitudes, with both knowledge and attitude improvements tending to return to baseline levels over-time. Interventions designed according to recommendations from previous research tend to increase both knowledge and attitudes with lack of follow-up data to determine long-term effects. Future concussion educational interventions should be designed according to expert opinion and using a knowledge transfer framework. The long-term effects of interventions require more research in order to design more effective educational tools.

Using the health belief model to predict concussion-reporting intentions and behaviour

PURPOSE

To determine whether Health Belief Model (HBM) factors predict concussion-reporting intentions and behaviour. Methods: Participants completed a cross-sectional survey to measure the HBM constructs of concussion knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. We also asked participants to indicate their concussion-reporting intentions and behaviourfor symptom and concussion reporting. Four separate multivariable regressions were conducted to predict concussion-reporting intentions and behaviour based on HBM constructs. Results: Cues to action (β = 0.25, p= .016) predicted symptom reporting intentions (F_7,318 = 4.44, p< .001, R² = 0.089), while perceived benefits (β = 0.12, p= .018), perceived barriers (β = -0.11, p= .034) and cues to action (β = 0.29, p< .001) predicted concussion-reporting intentions (F_7,318 = 11.34, p < .001, R² = 0.200). The HBM did not predict symptom or concussion-reporting behavior (symptom: Χ² = 5.51, p= .138, Nagelkerke R² = 0.096; concussion: Χ² = 5.20, p= .157, Nagelkerke R² = 0.159). Conclusions: Strategies to reduce perceived barriers and increase benefits of reporting concussion symptoms may improve reporting intentions. This may include cues to action in sharing a positive view toward long-term health and dispelling that reporting a concussion would let down teammates. .