Relationship Between Concussion History and Concussion Knowledge, Attitudes, and Disclosure Behavior in High School Athletes

Preliminary Baseline Vestibular Ocular Motor Screening Scores in Pediatric Soccer Athletes

CONTEXT

The utility of baseline vestibular and ocular motor screening (VOMS) in high school and collegiate athletes is demonstrated throughout the literature; however, baseline VOMS data at the youth level are limited. In addition, with the recent adoption of the change scoring method, there is a need to document baseline VOMS total and change scores in a pediatric population.

OBJECTIVE

To document baseline VOMS total and change scores and to document the internal consistency of the VOMS in pediatric soccer athletes. We hypothesized that the VOMS would demonstrate strong internal consistency in pediatric soccer athletes.

DESIGN

Cross-sectional study.

METHODS

Pediatric soccer athletes (N = 110; range = 5-12 y) completed the VOMS at baseline. Descriptive statistics summarized demographic information, VOMS total scores, and VOMS change scores. Cronbach α assessed internal consistency for VOMS total scores and change scores.

RESULTS

Twenty-one (19.1%) participants had at least one total score above clinical cutoffs (≥2 on any VOMS component and ≥5 cm on average near point convergence). Forty (36.4%) participants had at least one change score above clinical cutoffs (≥1 on any VOMS component and ≥3 cm on average near point convergence). The internal consistency was strong for total scores with all VOMS components included (Cronbach α = .80) and change scores (Cronbach α = .89).

CONCLUSIONS

Although results suggest VOMS items measure distinct components of the vestibular and ocular motor systems, caution should be taken when interpreting VOMS total and change scores in pediatric athletes, as overreporting symptoms is common, thereby impacting the false-positive rate.

Perceptions of personal control and treatment efficacy of sport-related concussions in collegiate athletes

OBJECTIVE

The purpose of this study was to examine healthy collegiate athletes' perceptions of personal control and beliefs regarding the treatment efficacy related to sport-related concussion (SRC) along with identifying factors that may be associated with these perceptions.

METHODS

This cross-sectional study included collegiate athletes (n = 956) between the age of 18-26 years. Participants completed a 10- to 15-min survey regarding their demographics, diagnosed SRC history, SRC knowledge, and Perceptions of Concussion Inventory for Athletes (PCI-A). Chi-squared analysis and multivariable logistic regressions were conducted to identify factors associated with the PCI-A outcomes of personal control and treatment efficacy perceptions.

RESULTS

24.2% of respondents reported higher perceptions of personal control, while 77.3% reported higher perceptions of treatment efficacy. The multivariable logistic regression revealed males had higher odds of greater perceptions of personal control (OR = 1.50; 95% CI: 1.10-2.03), while those with a history of diagnosed SRC had lower odds of having favorable treatment efficacy beliefs (OR: 0.69; 95% CI: 0.50-0.96).

CONCLUSIONS

This study established that collegiate athletes generally have lower perceptions of personal control and higher perceptions of treatment efficacy related to SRC recovery. Comprehensive SRC education should be expanded for individuals to understand that they have power over their own health outcomes and that SRC is a treatable injury.

The Influence of Athletic Identity, Passion, and Perceptions of Severity of Concussions on Athletes' Willingness to Report Concussion Symptoms

CONTEXT

The influence of several psychological characteristics on the willingness of athletes to report concussion behaviors has not been well explored. Therefore, the purpose of this study was to understand how athletic identity and sport passion predicted participants' willingness to report symptoms above what was explained by athlete demographics, concussion knowledge, and perceived seriousness of concussions.

DESIGN

The study was cross-sectional.

METHODS

Three-hundred and twenty-two male and female high school and club sport athletes completed survey measures of concussion knowledge, athletic identity, harmonious and obsessive passion, and degree to which athletes indicated they would report concussions and concussion symptoms.

RESULTS

Athletes scored moderately high on their knowledge of symptoms and other concussion information (mean = 16.21; ± = 2.88) and above the midpoint on their attitudes and behaviors toward reporting concussion symptoms (mean = 3.64; ± = 0.70). There were no differences between gender, t(299) = -.78, P = .44, and previous concussion education, t(296) = 1.93, P = .06, related to concussion knowledge. Results of a hierarchical regression indicated that after entering athlete demographics, concussion knowledge, and perceived seriousness of concussions, of the 3 psychological variables in the final stage of the model, only obsessive passion was a significant predictor of athlete's attitudes to report a concussion.

CONCLUSIONS

Perceived seriousness of concussion, perceived threat to long-term health, and obsessive passion were the strongest predictors of athlete's willingness to report concussions. Athletes who did not believe concussions posed a threat to their current or future health, and those that held an obsessive passion for sport were most at risk for not reporting concussions. Future research should continue to investigate the relationship between reporting behaviors and psychological factors.

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.

Question Format Matters: Do Athletes Really Know the Signs and Symptoms of a Sport-Related Concussion?

Authors of previous studies commonly used a multiselect checklist method to assess an athlete's ability to recognize true sport-related concussion (SRC) signs and symptoms (S&S) among incorrect distractor options. However, this may overinflate the evaluation of participants' knowledge because the multiselect method does not test athletes' ability to retrieve knowledge from their long-term memory. To examine this hypothesis, we sent an online survey to registered members of the Japan Lacrosse Association (n = 8530) to assess differences in reported SRC S&S by open-ended-question and multiselect formats. We also evaluated whether previous exposure to SRC education and a history of SRC influenced athletes' SRC S&S knowledge. The numbers and proportions of responses were calculated using descriptive statistics. The Pearson correlation was calculated to analyze the relationship between scores from the 2 question formats. Unpaired-samples t tests were conducted to compare the mean scores for each question format by previous SRC education and history of diagnosed SRC. Odds ratios were computed to express the relationship between the proportion of correct answers by question format per symptom. The response rate of the survey was 35.9% (n = 3065), and scores from the 2 question formats were correlated (r = 0.34, 95% CI = 0.31, 0.37; P < .001). For both question formats, athletes with previous exposure to SRC education and a history of SRC had a greater number of correct answers; however, the mean differences were trivial. Researchers and clinicians should acknowledge the difference between multiselect (recognition) and open-ended (free recall) formats when assessing one's understanding of SRC and managing athletes with a suspected SRC.

Factors and expectations influencing concussion disclosure within NCAA Division I athletes: A mixed methodological approach

BACKGROUND

Participation in sports is associated with many benefits to all aspects of health; however, it also comes with the risk of injury, particularly concussions. Self-disclosure and care seeking following a concussion are especially important because of the lack of outwardly visible signs and/or symptoms. Although recent research has explored factors affecting concussion disclosure, use of isolated methodologies limits the ability to contextualize how disclosure or nondisclosure occurs. Therefore, the purpose of this study was to describe the factors and expectations of National Collegiate Athletic Association (NCAA) athletes that may influence concussion disclosure.

METHODS

This mixed-methods convergent parallel research study included 25 NCAA Division I athletes representing 13 sports, all of whom completed a concussion-education session with pre-/post-test surveys and a semistructured interview. Eligible athletes were at least 18 years old and on an NCAA roster. The surveys focused on previous concussion-related disclosure behaviors, knowledge, attitudes, beliefs, norms, and intentions about disclosing concussion. Interviews focused on the athletes' experiences related to concussion disclosure. Survey data were analyzed using descriptive statistics and Mann-Whitney U tests. Interviews were analyzed using a Consensual Qualitative Research tradition.

RESULTS

Participants had good concussion knowledge (median = 46.0), positive attitudes (median = 38.0), strong beliefs (median = 13.0), and strong intentions to disclose concussion symptoms (median = 7.0). None of the constructs differed by participants' gender. Although quantitative findings were mostly positive, interview data highlighted factors that may explain why some participants are successful in disclosing concussions and why others may find disclosure difficult. Educational efforts, sport culture, and medical professional presence were the primary facilitators discussed by participants. Stigma, pressure, and a lack of team support were perceived as disclosure barriers.

CONCLUSION

The context in which concussion disclosure occurs or does not occur is vital to the success of educational interventions. Interventions must prioritize stakeholder- and team-based perspectives on concussion to establish a network supportive to disclosure.

Concussion knowledge, attitudes, and norms: How do they relate?

BACKGROUND

Relationships between the constructs of concussion-related knowledge, attitudes, and norms and their influence on observed care-seeking behaviors have previously been examined. Current models posit that these constructs serve as potential mediators of care-seeking behaviors; however, the dynamics between them have yet to be reconciled.

METHODS

A cross-sectional, online survey explored relationships among the latent constructs of concussion-related knowledge, attitudes, and norms in parents of middle school children who participate in sports in multiple settings. A just-identified and two overidentified path models were explored and compared in an effort to understand such relationships.

RESULTS

A total of 426 parents of United States middle school students were surveyed and included in analyses (mean age = 38.7±9.9 years; 55.6% female; 51.4% white/non-Hispanic; 56.1% with at least a bachelor's degree). All parents had middle school aged children who participated in sport in both the club and school settings. The best fitting model was a just-identified model with concussion-related norms influencing concussion-related knowledge and attitudes, and concussion-related knowledge influencing attitudes. This model accounted for 14% of the variance in attitude and 12% of the variance in knowledge.

CONCLUSIONS

Study findings suggest that the constructs of concussion-related knowledge, attitudes and norms are directly related to one another, yet the dynamics of such relationships may be complex. As such, a parsimonious interpretation of these constructs may not be appropriate. Future research should work to further reconcile the dynamics between these constructs, and the impact these dynamics may have in influencing care-seeking behaviors beyond serving as mediators.

Sport-related concussion disclosure in women's rugby-A social identity approach

Introduction

Sport-related concussion (SRC) is a risk of collision sports such as women's rugby. To support appropriate SRC diagnosis and management, an understanding of the factors that encourage SRC disclosure is necessary. To date, research has focused on ascertaining individual player knowledge and attitudes towards SRC disclosure.

Methods

We chose to investigate the potential influence of group identification effects by examining the role of social identity on SRC disclosure in elite women's rugby. Seventeen elite players from the United Kingdom and Ireland were interviewed and their transcripts thematically analysed.

Results

The data highlighted that the players shared a very strong social identity as women in rugby and were acutely aware that their experiences were different to their male counterparts. The shared social identity had both positive and negative implications for SRC disclosure. The players interviewed did not feel comfortable disclosing their symptoms to their coach and often felt that medical staff either did not listen to them or were unavailable to them. Mediators such as communication, trust in medical teams, perceived pressure, positive injury management experience, and player role models were identified.

Discussion

This research could be utilised to inform sport psychology interventions to enhance SRC disclosure in elite women's rugby.

Optimizing Concussion Care Seeking: Identification of Factors Predicting Previous Concussion Diagnosis Status

PURPOSE

There is limited understanding of factors affecting concussion diagnosis status using large sample sizes. The study objective was to identify factors that can accurately classify previous concussion diagnosis status among collegiate student-athletes and service academy cadets with concussion history.

METHODS

This retrospective study used support vector machine, Gaussian Naïve Bayes, and decision tree machine learning techniques to identify individual (e.g., sex) and institutional (e.g., academic caliber) factors that accurately classify previous concussion diagnosis status (all diagnosed vs 1+ undiagnosed) among Concussion Assessment, Research, and Education Consortium participants with concussion histories ( n = 7714).

RESULTS

Across all classifiers, the factors examined enable >50% classification between previous diagnosed and undiagnosed concussion histories. However, across 20-fold cross validation, ROC-AUC accuracy averaged between 56% and 65% using all factors. Similar performance is achieved considering individual risk factors alone. By contrast, classifications with institutional risk factors typically did not distinguish between those with all concussions diagnosed versus 1+ undiagnosed; average performances using only institutional risk factors were almost always <58%, including confidence intervals for many groups <50%. Participants with more extensive concussion histories were more commonly classified as having one or more of those previous concussions undiagnosed.

CONCLUSIONS

Although the current study provides preliminary evidence about factors to help classify concussion diagnosis status, more work is needed given the tested models' accuracy. Future work should include a broader set of theoretically indicated factors, at levels ranging from individual behavioral determinants to features of the setting in which the individual was injured.

The stability of self-reported professional football concussion history among former players: A longitudinal NFL-LONG study

OBJECTIVES

To examine the stability of former National Football League (NFL) players' recall of professional football concussion.

METHODS

Two-hundred-and-nine former NFL players (ceasing football participation before/in 2001) completed surveys in 2001, 2010, and 2019 and reported the number of concussions sustained during their professional careers (0, 1 … 10, >10). Participants were categorized into four 'recall stability' groups, based upon concussion recall [e.g., 'Same' (same number recalled), 'Increased' (more recalled than in prior time point)]. In 2019, participants completed measures of functioning (e.g., PROMIS Cognitive Function, Anxiety, Depression). Fleiss Kappa and generalized linear mixed models (GLMM)-based ordinal measures Kappa assessed stability across time points. 'Recall stability group' functioning scores were compared.

RESULTS

Overall, 45.9% recalled more concussions over time; 14.8% reported the same number. Fleiss Kappa and GLMM-based ordinal measures Kappa suggested fair (0.22, 95% CI: 0.26, 0.38) and moderate stability (0.41, 95% CI: 0.35, 0.46), respectively. Higher cognitive functioning (P = 0.002), lower anxiety (P = 0.003), and lower depression (P = 0.007) were observed in the 'Same' vs 'Increased' groups.

CONCLUSIONS

Despite subtle time-based variations in reporting, professional football concussion history recall was relatively stable. Better cognitive and psychological functioning was associated with greater stability in concussion recall.

Pediatric Sports-Related Concussion: An Approach to Care

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

Factors Related to Concussion Knowledge, Attitudes, and Reporting Behaviors in US High School Athletes: A Systematic Review

BACKGROUND

Sport-related concussions are a major public health problem with only 50% of concussed teens reporting their symptoms. The purpose of this systematic review was to identify individual and institutional factors that contribute to concussion knowledge, attitude, and reporting behaviors among US high school athletes.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol was used to direct the process of this systematic review. A search for English, peer-reviewed, quantitative studies published between 2010 and 2020 was conducted in 5 scholarly databases. The Joanna Briggs Critical Appraisal Tools were used to assess study quality.

RESULTS

Twenty-two studies met criteria for inclusion in this systematic review. The study designs were mostly cross-sectional (N = 18). Synthesis revealed individual factors including gender, age, race/ethnicity, grade level, and concussion history were associated with differences in concussion knowledge, attitude, and/or reporting behaviors. Institutional factors identified included school location, concussion education, access to an athletic trainer, sport played, and team climate. Six studies found concussion education had a positive impact on knowledge and reporting behaviors.

CONCLUSION

This systematic review identified certain populations which may be more vulnerable to underreporting concussion symptoms; therefore, a targeted approach to education and management may be more effective.

Beliefs affecting concussion reporting among military cadets: advanced observations through machine learning

BACKGROUND

Untreated concussions are an important health concern. The number of concussions sustained each year is difficult to pinpoint due to diverse reporting routes and many people not reporting. A growing body of literature investigates the motivations for concussion under-reporting, proposing ties with knowledge of concussion outcomes and concussion culture. The present work employs machine learning to identify trends in knowledge and willingness to self-report concussions.

METHODS

2,204 cadets completed a survey addressing athletic and pilot status, concussion symptoms and outcome beliefs, ethical beliefs, demographics, and reporting willingness.

RESULTS

Clustering and non-negative matrix analysis identified connections to self-report willingness within: knowledge of symptoms, ethical beliefs, reporting requirements, and belief of long-term concussion outcomes. Support vector machine classification of cadet reporting likelihood reveals symptom and outcome knowledge may be inversely related to reporting among those rating ethics considerations as low, while heightened ethics may predict higher reporting likeliness overall.

CONCLUSIONS

Machine-learning analysis bolsters prior theories on the importance of concussion culture in reporting and indicate more symptom knowledge may decrease willingness to report. Uniquely, our analysis indicated importance of ethical behavior may be associated with general concussion reporting willingness, inviting further consideration from healthcare practitioners seeking increased reporting.

Epidemiology of Pediatric Basketball Injuries Presenting to Emergency Departments: Sex- and Age-Based Patterns

Background:

There is limited epidemiologic data on pediatric basketball injuries and the comparison of these injuries before and after adolescence and between male and female athletes.

Purpose:

To assess common sex- and age-based injury patterns in pediatric basketball players.

Study Design:

Descriptive epidemiology study.

Methods:

Injury data from the National Electronic Injury Surveillance System (NEISS) and participation data from the National Sporting Goods Association were used to complete this study. Data on pediatric basketball injuries between January 2012 and December 2018 in patients aged 7 to 11 years (childhood) and 12 to 17 years (adolescence) were extracted and used to calculate national injury incidence rates with 95% CIs. Sex and age group patterns were examined utilizing Pearson chi-square tests. Z tests were conducted for the comparison of injury rates between female and male athletes in each age group and overall injury rate across age groups.

Results:

An average of 9582 basketball injuries were reported annually in the NEISS, which calculated to an annual national estimate of 294,920 injuries. The most common diagnoses were ankle strain/sprain (17.7%), finger strain/sprain/fracture (12.1%), concussion/head injury (9.4%), knee strain/sprain (4.5%), and facial laceration (3.3%). There was a significant increase in injury prevalence in adolescents (12- to 17-year-old category: 238,678 injuries per year) when compared with childhood (7- to 11-year-old category: 56,242 injuries per year) (P < .0001). Concussions/head injuries occurred at a high rate in childhood, second only to finger strain/sprain/fracture, and at a similar rate in females and males (injuries per 100,000 athlete-days: 4.9 [95% CI, 3.1-6.7] vs. 5.9 [4.3-7.5], respectively; P = .41). From childhood to adolescence, injury prevalence increased for all areas and across both sexes, except for female finger strain/sprain/fracture; however, the rate of increase for concussion/head injuries and knee injuries was significantly higher in female compared with male athletes (P < .0001 for both). In adolescents, ankle injuries were the most common injury overall.

Conclusion:

Ankle injuries continue to be the most predominant pediatric basketball injury. However, disproportionate rates of both knee and concussion/head injuries in female athletes during adolescent basketball are of concern and have implications for injury prevention.

Concussion Knowledge and Reporting Behaviors Among Collegiate Athletes

OBJECTIVE

The purpose of the current study was to explore knowledge surrounding sport-related concussions (SRCs) and the impact on reporting behaviors in collegiate athletes, including sex differences.

DESIGN

Cross-sectional.

SETTING

Institutional.

PARTICIPANTS

Participants were 986 collegiate athletes (607 men), aged 19.7 years (SD = 1.4) from 6 institutions, who completed a survey, including items on personal/sport demographics and SRC knowledge and reporting behaviors.

INTERVENTIONS

Athletes were given a short (15-minute) survey to complete during team meetings and preparticipation physicals.

MAIN OUTCOME MEASURES

Athletes' scores on the survey, and reporting behaviors (ie, whether or not they failed to report a suspected SRC and reasons for not reporting SRCs), were examined.

RESULTS

Independent samples t tests revealed female athletes scored significantly higher than male athletes on total SRC knowledge [t (926.6) = -10.6, P < 0.01] and symptom knowledge (t (859) = -7.0, P < 0.01). Approximately one-quarter of athletes reported continuing to play after sustaining a suspected SRC. Chi-square analyses exposed significant differences between male and female athletes failing to report a suspected SRC (χ2 = 7.69, P < 0.01).

CONCLUSIONS

Given the current findings, educational efforts aimed at collegiate athletes may not be enough. Furthermore, it is apparent that sex differences exist in SRC knowledge and reporting behaviors among collegiate athletes.

Development of a scale to measure expected concussion reporting behavior

Background

Most concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes.

Methods

A mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9–16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155).

Results

Internal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to “always” tell their coach about symptoms of a suspected concussion.

Conclusions

The CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00364-4.

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.

Reporting of Concussion Symptoms by a Nationwide Survey of United States Parents of Middle School Children

This cross-sectional study assessed concussion symptom knowledge of parents of middle school (MS) children (aged 10-15 years) through a free-response item that solicited concussion symptoms and compared findings to a pre-validated scale-based measure. A self-administered online questionnaire was sent to a panel of randomly selected United States residents who were recruited by a third-party company, aged ≥ 18 years, and identified as parents of MS children. Via a free-response item, parents listed what they believed were concussion symptoms. Multiple sections later, parents identified potential concussion symptoms via a scale measure, which featured 25 items (22 actual symptoms, three distractor symptoms) with three response options: yes, no, maybe. Free-response item responses were coded into specific symptoms. The 1062 eligible parents that provided complete data commonly identified the symptoms of dizziness (90.2%), blurred vision (87.4%), and balance problems (86.4%) on the scale-based measure. However, these and other symptoms were less commonly identified via the free-response item (dizziness: 44.4%; blurred vision: 16.5%; balance problems: 3.5%). Concussion symptoms commonly reported via the scale-based measure were reported less frequently within the free-response item. Future research must explore strategies to help clinicians working with parents and their children to measure and assess concussion symptom reporting and knowledge.

The burden of unsubstantiated messaging: collegiate athletes' chronic traumatic encephalopathy mechanism beliefs

OBJECTIVE

To investigate factors associated with collegiate athletes' beliefs regarding chronic traumatic encephalopathy (CTE) mechanism.

DESIGN

Cross-sectional study.

METHODS

A total of 838 collegiate athletes (61.9% men) from seven institutions completed a 10-minute survey that captured information relative to demographics, diagnosed concussion history, formal sport-related concussion education, additional sources of concussion information, and beliefs about multiple concussions and premature return-to-play following a head impact as mechanisms for CTE.

RESULTS

More than half of collegiate athletes believed that multiple concussions (58.2%) and premature return-to-play (59.1%) may cause CTE. Those who reported getting concussion information from sports news had higher odds of believing multiple concussions and premature return-to-play were CTE mechanisms compared to those who did not get information from sports news sources. Additionally, CTE mechanism beliefs were significantly greater in collegiate athletes who were male, had sustained a previous diagnosed concussion, or had acquired concussion information from the NCAA.

CONCLUSIONS

Sports news' reporting of CTE storylines, which highlight former male athletes with complex brain injury histories, may influence collegiate athletes' beliefs about concussion. Therefore, it is recommended that concussion awareness initiatives incorporate information related specifically to CTE to empower collegiate athletes with evidence-based, patient-oriented information and knowledge regarding this condition.

Continued play following adolescent sport-related concussion: Prospective data from the North Texas Concussion Registry (ConTex)

Our study aims were to identify the frequency of continued play following sport-related concussion (SRC), defined as continuing athletic activity on the same day following a suspected SRC, characteristics associated with continued play, and whether continued play was associated with worse outcomes. A prospective study of participants ages 13-18 years diagnosed with SRC at a pediatric sports medicine clinic over a 4-year period was conducted. A comparison was performed between athletes who reported continued play following SRC (PLAY) and those who did not (NO PLAY). Of 441 participants, 231 (52.4%) were in the PLAY group. The PLAY group recalled less severe balance problems from the day of injury (p = 0.02), but reported greater symptoms of trouble falling asleep, concentrating, and remembering at their initial clinic visit (p < 0.05). There was no difference in recovery time between groups. Greater symptom severity score at the initial clinic visit and longer time to presentation were associated with prolonged recovery in both groups (p < 0.01). In conclusion, more than half of the athletes in this sample continued to play on the same day following SRC. Our results indicate the need for a heightened focus on education and additional efforts to reduce continued play following SRC in adolescents.

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.

Does time since concussion alter the factor structure of a multidomain assessment in adolescents?

The utilization of principal component analysis (PCA) approaches to concussion is beneficial to inform the interpretation of clinical outcome data in adolescent patients. While researchers have identified factors using post-concussive symptom scales and cognitive testing, there has yet to be a PCA that incorporates vestibular or oculomotor outcomes, or that focuses exclusively on adolescents. Moreover, the role of time since injury has not been examined in relation to concussion factors in this at-risk population. PCA methods were applied to two independent samples of 237 adolescents who presented to an outpatient concussion clinic: 1) ≤7 days (n = 145), and 2) 8 days-1 month (n = 92). The two separate PCAs included nine clinical assessments comprised of: a) four symptoms factors (cognitive/fatigue/migraine, affective, somatic, sleep), b) memory and speeded cognitive performance, c) near point of convergence (NPC), d) oculomotor, and e) vestibular outcomes. A three-component model including 1) symptoms, 2) cognitive, and 3) vestibular/oculomotor factors that accounted for 69.2% of the variance was supported for the ≤7 days sample. All items except somatic symptoms loaded. A different three-component model was supported for the 8 days-1 month sample, including 1) vestibulo-ocular migraine, 2) visuo-cognitive, and 3) affective-sleep that accounted for 72.1% of the variance, with all items loading. The findings supported two different concussion factor models that highlight the influence of time since injury and importance of considering vestibular and oculomotor outcomes in adolescents. Clinicians should evaluate these different factors using a comprehensive, multi domain approach to better inform assessment and monitor recovery in adolescent patients following concussion.Abbreviations: Principal Components Analysis (PCA), Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Post-concussion Symptom Scale (PCSS), Vestibular/Ocular Motor Screening (VOMS).

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.

Factors Associated With Concussion Nondisclosure in Collegiate Student-Athletes

CONTEXT

Mandated concussion education has aimed to improve student-athlete knowledge; however, some collegiate student-athletes continue to not disclose concussion. Concussion knowledge may not be the only factor influencing reporting, as student-athlete sex, sport, and pressure from external stakeholders (eg, coaches, teammates, fans, parents or family) have all been documented as influencing collegiate concussion-reporting behavior.

OBJECTIVE

To examine factors associated with concussion nondisclosure in collegiate student-athletes.

DESIGN

Cross-sectional study.

SETTING

Four National Collegiate Athletic Association Division I and two Division II universities.

PATIENTS OR OTHER PARTICIPANTS

A total of 1125 collegiate student-athletes completed the survey, and 741 provided viable responses and were included for data analysis.

MAIN OUTCOME MEASURE(S)

We used a 10- to 15-minute electronic or paper-and-pencil survey that asked about personal and sport demographics, diagnosed concussions and nondisclosed concussion history, concussion knowledge, and level of agreement regarding pressure to play after a head impact experienced during collegiate sport participation. Significant univariable factors were entered into a multivariable logistic regression analysis.

RESULTS

Sex (P = .005), sport-risk type (P < .001), diagnosed concussion history (P < .001), concussion knowledge (P = .017), and pressure from coaches (P < .001), teammates (P < .001), fans (P = .024), and parents or family (P = .003) were factors associated with concussion nondisclosure in individual univariable logistic regressions. After we conducted multivariable analyses, male sex (P = .001), high concussion-risk sport participation (P = .048), diagnosed concussion history (P < .001), increased concussion knowledge (P = .013), and experiencing pressure from coaches to continue playing after sustaining a hit to the head (P = .002) were factors associated with concussion nondisclosure in collegiate student-athletes.

CONCLUSIONS

Our results suggest that concussion-education programs should go beyond the identification of signs and symptoms to include the dangers of continuing to play, long-term consequences, and transparency about concussion protocols. Comprehensive concussion-education programs should involve coaches and athletes to improve the reporting culture.

Concussion Education in Children and Youth: A Scoping Review

Introduction

Sports-related concussions in children and youth are a significant health concern. There is increasing literature pertaining to levels of knowledge about concussion and the effects of educational interventions, but the literature has not yet been synthesized for the subpopulation of children and youth. Therefore, the purpose of this review was to identify and summarize the current state of the literature on concussion knowledge, and the effect of concussion education on the knowledge, attitudes, and behaviors of children and youth who engage in sports.

Methods

A scoping review was conducted, guided by Joanna Briggs Institute methodology. Two databases, MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature), and reference lists were searched to identify relevant studies that focused on children and youth less than 19 years of age who engage in sports. We also searched Google Scholar for gray literature.

Results

Of the 21 articles that met inclusion criteria, 15 focused on levels of concussion knowledge, and 6 examined the effects of educational interventions. Children and youths’ level of knowledge and exposure to prior concussion education varied, although more of the studies found a lack of concussion knowledge. Educational interventions of various types have been associated with short-term increases in knowledge and intention to report, but few of the studies found sustained effects.

Conclusions

Findings highlight the need for improved concussion education for children and youth engaged in sports. Findings also indicate a need for further research using more rigorous methods, and studies that examine subgroup differences in knowledge and factors that may moderate the effects of educational interventions.

Differences in sport-related concussion for female and male athletes in comparable collegiate sports: a study from the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium

OBJECTIVES

To examine sex differences in sport-related concussion (SRC) across comparable sports.

METHODS

Prospective cohort of collegiate athletes enrolled between 2014 and 2017 in the Concussion Assessment, Research and Education Consortium study.

RESULTS

Among 1071 concussions (females=615; 57.4%), there was no difference in recovery (median days to full return to play) (females=13.5 (IQR 9.0, 23.1) vs males=11.8 (IQR 8.1, 19.0), p=0.96). In subgroup analyses, female recovery was longer in contact (females=12.7 days (IQR 8.8, 21.4) vs males=11.0 days (IQR 7.9, 16.2), p=0.0021), while male recovery was longer in limited contact sports (males=16.9 days (IQR 9.7, 101.7) vs females=13.8 days (IQR 9.1, 22.0), p<0.0001). There was no overall difference in recovery among Division I schools (females=13.7 (IQR 9.0, 23.1) vs males=12.2 (IQR 8.2 19.7), p=0.5), but females had longer recovery at the Division II/III levels (females=13.0 (IQR 9.2, 22.7) vs males=10.6 (IQR 8.1, 13.9), p=0.0048).

CONCLUSION

Overall, no difference in recovery between sexes across comparable women's and men's sports in this collegiate cohort was found. However, females in contact and males in limited contact sports experienced longer recovery times, while females had longer recovery times at the Division II/III level. These disparate outcomes indicate that, while intrinsic biological sex differences in concussion recovery may exist, important, modifiable extrinsic factors may play a role in concussion outcomes.

Is It Time to Give Athletes a Voice in the Dissemination Strategies of Concussion-Related Information? Exploratory Examination of 2444 Adolescent Athletes

OBJECTIVE

The objective of the research was to screen male and female adolescent athletes on their concussion educational histories and preferred future methods of education in terms of educational messenger, modality, and concussion-related areas of interest.

DESIGN

Cross-sectional survey.

SETTING

Examination setting within the classroom.

PARTICIPANTS

Adolescent male (n = 1854) and female (n = 590) athletes aged 12 to 18 years.

MAIN OUTCOME MEASURES

To explore the concussion educational histories and preferred future methods of education in Irish male and female adolescent athletes.

RESULTS

19.7% (n = 482) of the sample received education in the past 12 months. Male athletes had a significantly higher rate of previous education than female athletes (41% vs 17%). The methods used in previous educational interventions are failing to match the interests of the athletes. Sex played a significant role in the preferred educational methods, as male and female athletes had significant differences in their choice of educational messenger, modality, and concussion-related areas of interest.

CONCLUSIONS

The current disparity in previous concussion education rates between male and female adolescent athletes should be addressed. Forthcoming research should explore the efficacy of tailoring knowledge translation strategies to match the specific needs of the recipient.

Concussion-Recovery Trajectories Among Tactical Athletes: Results From the CARE Consortium

CONTEXT

Assessments of the duration of concussion recovery have primarily been limited to sport-related concussions and male contact sports. Furthermore, whereas durations of symptoms and return-to-activity (RTA) protocols encompass total recovery, the trajectory of each duration has not been examined separately.

OBJECTIVE

To identify individual (eg, demographics, medical history), initial concussion injury (eg, symptoms), and external (eg, site) factors associated with symptom duration and RTA-protocol duration after concussion.

DESIGN

Cohort study.

SETTING

Three US military service academies.

PATIENTS OR OTHER PARTICIPANTS

A total of 10 604 cadets at participating US military service academies enrolled in the study and completed a baseline evaluation and up to 5 postinjury evaluations. A total of 726 cadets (451 men, 275 women) sustained concussions during the study period.

MAIN OUTCOME MEASURE(S)

Number of days from injury (1) until the participant became asymptomatic and (2) to complete the RTA protocol.

RESULTS

Varsity athlete cadets took less time than nonvarsity cadets to become asymptomatic (hazard ratio [HR] = 1.75, 95% confidence interval = 1.38, 2.23). Cadets who reported less symptom severity on the Sport Concussion Assessment Tool, third edition (SCAT3), within 48 hours of concussion had 1.45 to 3.77 times shorter symptom-recovery durations than those with more symptom severity. Similar to symptom duration, varsity status was associated with a shorter RTA-protocol duration (HR = 1.74, 95% confidence interval = 1.34, 2.25), and less symptom severity on the SCAT3 was associated with a shorter RTA-protocol duration (HR range = 1.31 to 1.47). The academy that the cadet attended was associated with the RTA-protocol duration (P < .05).

CONCLUSIONS

The initial total number of symptoms reported and varsity athlete status were strongly associated with symptom and RTA-protocol durations. These findings suggested that external (varsity status and academy) and injury (symptom burden) factors influenced the time until RTA.

What they know and who they are telling: Concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players

The purpose of this study was to survey high school rugby players from a range of ethnic, geographic and socioeconomic backgrounds in New Zealand (NZ) to gain an understanding of concussion knowledge, awareness of NZ Rugby's (NZR) guidelines and attitudes towards reporting behaviours. Male and female high school rugby players (n= 416) from across NZ were surveyed. The findings indicated that 69% of players had sustained a suspected concussion, and 31% had received a medical diagnosis of concussion. 63% of players indicated they were aware of NZR's guidelines. Māori and Pasifika players were less likely to be aware of the guidelines compared to NZ European, Adjusted OR 0.5, p = 0.03. Guideline awareness was significantly higher for those from high decile schools when compared to low (Unadjusted OR 1.63, p = 0.04); however, when ethnicity and school locations were controlled for this became non-significant (Adjusted OR= 1.3, p=0.37). The coach was the key individual for the provision of concussion information and disclosure of symptoms for players. The findings of this study will inform the development and delivery of NZR's community concussion initiative and how these examined factors influence a high school player's concussion knowledge and reporting behaviour.

Cross-Sectional Investigation of Self-Reported Concussions and Reporting Behaviors in 866 Adolescent Rugby Union Players: Implications for Educational Strategies

OBJECTIVE

To examine the self-recalled concussion and bell ringer (BR) prevalence, reporting rates, and reporting behaviors in adolescent rugby players.

DESIGN

Cross-sectional survey.

SETTING

School classroom.

PARTICIPANTS

Adolescent male rugby players aged 12 to 18 years (n = 866).

MAIN OUTCOME MEASURES

Concussion and BR prevalence, reporting rates, and reporting behaviors.

RESULTS

The sample reported a concussion and BR prevalence rate of 40% and 69.9%, respectively. Of these athletes with a history, 38.4% and 86.4% suffered recurrent concussions and BRs, respectively. The total reporting rates per 1000 suspected concussions and BRs were 474.8 [95% confidence interval (CI), 415.4-534.3] and 238.7 (95% CI, 217.8-259.5), respectively. The athletes highlighted several barriers which hindered their truthful reporting of concussion, including "not thinking the injury is serious enough to report" (70%), "wanting to win the game" (38%), and "not wanting to miss future games or training" (48%).

CONCLUSIONS

Educational interventions are an invaluable component within a socioecological framework aimed at improving the concussion reporting rates of adolescent athletes. The self-recalled prevalence, underreporting rates, and behaviors of the sample are alarming, which prompts the need to further explore their motivational beliefs behind their decision to underreport a potential concussion. The information obtained can be used to tailor personalized interventions for specific athlete samples.

The Changing Landscape of Sport Concussion

It was not too long ago that many people referred to concussion as a “hidden injury” and a “complex injury for which we still had much to learn.” We still have a lot to learn about these injuries, but because of the advancement of concussion research we are better informed today than we were just a decade ago. Much of this work began in the early to mid-1990s with studies aimed at equipping clinicians with better concussion-assessment tools. We needed to remove the guesswork, so more systematic and objective concussion-assessment batteries (sideline and clinic) that included symptom checklists, cognitive tests, and balance assessments were developed and validated. As a result, it became easier to detect and/or rule out concussions and to track recovery for several days postinjury. From 2009 through 2014, all 50 states and the District of Columbia passed concussion legislation requiring concussion education for high school and youth athletes, among other things. This was a critical period in which more emphasis was placed on concussion prevention, ultimately leading to increased reporting of these injuries and a reduction in the number of unreported and undiagnosed concussions. More recently, the corpus of science has evolved to identify potential blood and neuroimaging biomarkers to complement the traditional-clinical assessment tools, and newer studies are focused on treatment after concussion—challenging the notions that “rest is best” and that the effects of concussion are permanent and immutable. The research is ongoing, and several large multisite studies will yield important findings to help guide clinical decision making in the next few years.

Perceived social norms and concussion-disclosure behaviours among first-year NCAA student-athletes: implications for concussion prevention and education

Timely disclosure and identification of concussion symptoms are essential to proper care. Perceived social norms are a potential driving factor in many health-related decisions. The study purpose was to describe concussion disclosure behaviours and identify the association between perceived social norms and these disclosure behaviours. First-year student-athletes (n = 391) at two NCAA institutions completed a cross-sectional survey about concussion disclosure and disclosure determinants. Log-binomial regression models identified factors associated with concussion disclosure behaviour prevalence for: higher intention to disclose symptoms, disclosed all at time of injury, eventually disclosed all, and never participated with concussion symptoms. More favourable perceived social norms were associated with higher prevalence of intention to disclose (PR = 1.34; 95%CI: 1.18, 1.53) and higher prevalence of never participating in sports with concussion symptoms (PR = 1.50; 95%CI: 1.07, 2.10). Clinicians, coaches, sports administrators, and healthcare practitioners should be mindful of the need to create supportive social environments to improve concussion symptom disclosure.

Influence of Concussion Education Exposure on Concussion-Related Educational Targets and Self-Reported Concussion Disclosure among First-Year Service Academy Cadets

Introduction

Concussion disclosure is often essential for military personnel to receive appropriate care following concussive injury. Concussion-related education and training may play a role in improving disclosure and recognition among peers, allowing for more timely concussion identification and treatment. The objectives of this study were to: (1) describe concussion education exposure among first-year service academy cadets and (2) examine the association between exposure to concussion education sources (multiple vs. only one) and concussion-related knowledge, attitudes, perceived social norms, intention to disclose symptoms, and disclosure behaviors.

Materials and Methods

First-year service academy cadets completed a cross-sectional survey to assess perceptions of concussion disclosure during preseason concussion baseline testing sessions. Associations between key cadet characteristics and exposure to multiple concussion education sources were examined using odds ratios and 95% confidence intervals. Linear regression was used to model the continuous measures of concussion-related knowledge, attitudes, and perceived social norms. Log-binomial regression was used to model the categorical outcomes of high perceived control over concussion disclosure (higher vs. lower), intention to disclose (higher vs. lower), and disclosure of all possible concussive events at the time of injury (yes vs. no). The primary predictor for all models was exposure to multiple sources of concussion education (video, coach, medical professional, or other) vs. exposure to only one educational source. All models were adjusted for gender, high school contact sport participation, and previous concussion history.

Results

Of the 972 first-year cadets (85% response; age = 18.4 ± 0.9 years; 21.7% female, 29.0% NCAA student-athlete), 695 (71.5%) reported receiving some type of previous concussion education and 229 (23.6%) reported a previous concussion history (206/229 reported the actual number they experienced). Of those reporting previous concussion-related education (n = 695), 542 (78.0%) watched a video, 514 (74.0%) talked with a coach about concussion, 433 (62.3%) talked with a medical professional, and 61 (8.8%) reported other sources of education ranging from anatomy teachers to brochures. Overall, 527 (75.8%) reported receiving more than one source of concussion education. Having played a contact sport in high school and having a history of concussion were associated with having multiple concussion education exposures. Being female was associated with lower odds of multiple exposures. Exposure to multiple sources of concussion education was not associated with knowledge, attitudes, perceived norms, or higher intention to disclose concussion symptoms. However, among those with a concussion history, exposure to multiple sources of concussion education was associated with a nearly 40% higher prevalence of disclosing all concussions at the time of injury compared to only one source of educational exposure (67.1% vs. 48.3%; prevalence ratio = 1.4; 95% confidence interval: 0.9, 2.1). Thus, although multiple sources of education may not influence intermediate variables of knowledge, attitudes, perceived norms and intentions, exposure to multiple sources of concussion education may influence actual decision-making around concussion disclosure among first-year service academy cadets.

Conclusion

These data suggest disparities in concussion education exposure that can be addressed in first-year cadets. Additionally, findings support the importance and use of multiple sources of concussion education in improving cadet’s concussion-related decision-making.

Direct Verbal Communication by Parents, Pressure Related to Sport Achievement, and Concussion Safety in Youth Football

Direct verbal communication from parents about concussion safety and parent pressure related to sport achievement may influence concussion risk-related behavior among youth athletes. This study assessed whether less parental pressure related to sport achievement and more parental communication about concussion safety were associated with lower intentions to continue sport participation while experiencing concussion symptoms. Participants were youth football players (ages 10-14) and their parents (n = 278 dyads, response rate = 45%). Structural equation modeling was used to predict the athlete's intention to continue play with concussive symptoms. One quarter of parents had never talked with their child about any concussion safety topic, and more than half had not talked about concussion safety within the past year. Greater parent communication about concussion and less pressure on sport achievement were both associated with lower child intention to continue playing while symptomatic post-concussion. Parents who placed more pressure on their child related to sport achievement were less likely to talk about concussion safety with their child. Determining how to shape parenting that is supportive of concussion safety is an important avenue for future health education program development work. This may include efforts to parenting behaviors in the sport context that reinforce effort rather than winning.

A New Game Plan for Concussion Education

Despite state laws requiring concussion education for youth sport stakeholders and a proliferation of educational programs, there has been little demonstrated impact on concussion reporting behaviors. We propose that this is because of four key limitations to existing approaches to concussion education: (1) deliberative decision making by the injured athlete is assumed, (2) interventions are often targeted at individuals rather than social systems, (3) education occurs once during preseason and is forgotten, and (4) dissemination challenges exacerbate health inequalities. Addressing these limitations, we propose a novel theoretic framework that situates individual behavior within a sport system's culture and their broader structural context. Concussion education programs should seek to facilitate safety-supportive interpersonal communication within and between stakeholder groups and influence attributes of groups that drive behavior, including shared values. Addressing the limitations outlined and drawing on the proposed conceptual framework, we describe a novel approach to concussion education: pregame safety huddles.

Concussion reporting, knowledge and attitudes in Irish amateur gaelic games athletes

OBJECTIVES

To examine self-reported concussion history, knowledge and attitudes towards concussion reporting and education in Irish adult Gaelic games players.

DESIGN

Cross-sectional survey.

SETTING

Data were collected using an online survey instrument.

PARTICIPANTS

Two hundred and sixteen adult Gaelic games athletes (106 male, 110 female).

MAIN OUTCOME MEASURES

Self-reported concussion history for the previous season, reporting history for participants' most recent concussion, concussion knowledge, willingness to report future concussions in a variety of situations and desire for further concussion education.

RESULTS

Seventy-three percent of participants suspected they had sustained a concussion in the past. Most (72.2%) informed someone of their most recent concussion, although two-thirds continued to play during their most recent concussion. Participants had a good overall understanding of concussion, although concussion knowledge score was not associated with safer behaviour following participants' most recent concussion. While most agreed that concussion is a serious injury (95.8%), 46.8% would not report a concussion during important games.

CONCLUSIONS

The high proportion of participants playing following concussion and their reluctance to report concussions during important games is concerning. Interventions aimed at improving attitudes towards concussion reporting among athletes and other stakeholders are required to improve concussion management in amateur Gaelic games athletes.

Pilots and athletes: Different concerns, similar concussion non-disclosure

Objectives

Concussion non-disclosure research has focused almost exclusively on athletes. The focus on athletic populations has been sensible considering athletes’ demonstrated susceptibility to sustaining and concealing concussions. Nevertheless, the habitual use of athletic populations has allowed researchers and practitioners to omit the development of generalized perceived costs and perceived rewards as critical determinants of concussion self-disclosure. We hypothesized that perceiving concussion disclosure as generally more costly than rewarding would predict negative attitudes towards disclosure and decreased intent to disclose. We also hypothesized that generalized perceived costs and rewards could explain concussion non-disclosure in different populations, athletes and future pilots specifically, even when those populations perceive concussion self-disclosure as costly for different specific reasons.

Methods

We examined concussion disclosure using 2,504 cadets at the United States Air Force Academy. Cadets completed anonymous surveys assessing their intention to self-disclose undiagnosed concussions (Anticipated Concussion Disclosure) as well as several variables potentially related to concussion self-disclosure: perceived cost, perceived reward, personal identity, attitudes, normative behavior, social support, and self-efficacy.

Results

The results demonstrate that concussion non-disclosure develops when a population perceives disclosure as more costly (i.e. directly or emotionally) and less rewarding. Perceived Cost and Perceived Reward variables alone accounted for 50% of the variance in Anticipated Conclusion Disclosure (Adjusted R²= 0.50, F(2,2312) = 1,145.31, p < 0.001). As expected, Anticipated Conclusion Disclosure developed for different reasons within different sub-populations. Consistent with existing research, cadet intercollegiate athletes reported being primarily concerned that concussion self-disclosure would cause them to miss practice or game time (t (736.7) = 14.20, p < .001, Cohen’s d = 0.96). In contrast, cadet future pilots reported being primarily concerned that concussion self-disclosure would have negative United States Air Force career repercussions (t (1828) = 10.25, p < .001, Cohen’s d = 0.50).

Conclusions

These results suggest that cultures of concussion non-disclosure can develop in any population where disclosure is perceived as having undesirable consequences, not just athletic populations. Concussion researchers and practitioners should devote more attention to the perceived cost-benefit structures that create concussion non-disclosure to address this crucial public health issue more effectively.

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.

Improving Concussion-Reporting Behavior in National Collegiate Athletic Association Division I Football Players: Evidence for the Applicability of the Socioecological Model for Athletic Trainers

CONTEXT

Few researchers have examined the views of important stakeholders in football student-athletes' spheres of influence and whether their views map well in a systems approach to understanding concussion-reporting behavior (CRB).

OBJECTIVE

To examine the extent to which stakeholders' beliefs about what influences football players' CRBs reflect system-level influences that go beyond individual-level factors.

DESIGN

Qualitative study.

SETTING

Four National Collegiate Athletic Association Division I university athletic programs.

PATIENTS OR OTHER PARTICIPANTS

A total of 26 individuals (athletic directors = 5, athletic trainers [ATs] = 10, football coaches = 11).

DATA COLLECTION AND ANALYSIS

Semistructured interviews with stakeholders were transcribed and analyzed using the socioecological model according to the Miles and Huberman coding methods.

RESULTS

Stakeholders largely identified individual-level factors (attitudes), followed by exosystem-level factors (university policies and support for ATs), with fewer microsystem- and mesosystem-level factors (coach influence and communication between coaches and ATs, respectively) and almost no macrosystem-level factors (media influence, cultural norms about aggression and toughness in football).

CONCLUSIONS

Promising evidence indicates growing stakeholder awareness of the importance of exosystem-level factors (eg, medical personnel and CRB policies) in influencing CRB rates. However, frontline stakeholders and policy makers may benefit from practices that bridge these influences (eg, coach involvement and communication), allowing for a more integrated approach to influence student-athletes' willingness to improve their CRBs.

A Simple Field-Based Tool to Assess Concussion Symptom Reporting Behavior

INTRODUCTION

Prevention and treatment of sport-related concussions is an important public health issue and has led to increased research on concussion symptom reporting behavior. To date, there is neither a common understanding of what constitutes concussion symptom reporting behavior nor measures that capture key features of concussion symptom reporting behavior. Concussion symptom reporting behavior can be initiated by an athlete, an athletic trainer, coach, or teammate and can occur in competition, practice, or days after symptoms appear. Follow-up diagnostics range from asking athletes initial questions about their symptoms to conducting rapid standardized sideline assessments to conducting full comprehensive concussion screens. Currently, for athletes who are not formally diagnosed with concussion, no information about concussion symptom reporting behavior sources, screening methods, or context is collected.

METHODS

Pilot data were collected from four National Collegiate Athletic Association Division I football programs. Athletic trainers recorded data about key concussion symptom reporting behavior features during the 2016 and 2017 football seasons. The 2016 data were analyzed in Spring 2017 and the reporting form was adapted for the Fall 2017 season. Two programs completed records during the 2017 season. These records were analyzed in Spring 2018.

RESULTS

Concussion symptom reporting behavior is most often initiated by athletes in practice contexts, followed by athletic trainers in game contexts. The 2017 data revealed that, regardless of source, 45% of initial screens received a comprehensive screen and about 25% of comprehensive screens originated by athlete or athletic trainer concussion symptom reporting behavior resulted in concussion diagnosis. Results led to development of a brief concussion symptom reporting behavior recording tool that can be used in practice, game, and athletic training room settings.

CONCLUSIONS

The smartphone-supported Concussion Symptom Reporting Tool provides a rapid and easy way to record concussion symptom reporting behavior as well as estimate program-specific data for stakeholders interested in understanding concussion symptom reporting behavior.

Determinants of intention to disclose concussion symptoms in a population of U.S. military cadets

OBJECTIVES

Non-disclosure of concussion complicates concussion management, but almost nothing is known about non-disclosure in military settings. This study describes concussion disclosure-related knowledge, attitudes, perceived social norms, perceived control, and intention. Additionally, the study identifies determinants of high intention to disclose concussion symptoms.

DESIGN

Cross sectional survey.

METHODS

First-year service academy cadets completed a cross-sectional survey to assess perceptions of concussion disclosure. Independent variables included: gender, race, ethnicity, high school athlete status, NCAA athlete status, previous concussion history, previous concussion education, socioeconomic proxy, concussion-related knowledge, attitudes about concussion, perceived social norms (perceived peer/organizational support and actions), and perceived control over disclosure. Log-binomial regression was used to identify determinants of high intention to disclose concussion symptoms.

RESULTS

A total of 972 first-year military service academy cadets completed the survey [85% response; age=18.4±0.9y]. In the simple models, previous concussion history was associated with lower intention to disclose concussion symptoms. High perceived control over disclosure, higher concussion knowledge, more favorable attitudes and social norms about concussion were associated with high intention to disclose. In the multivariable model, a 10% shift towards more favorable perceived social norms (PR=1.28; p<0.001) and attitudes (PR=1.07; p=0.05) about concussion were associated with high intention to disclose concussion symptoms. High perceived control over disclosure was associated with high intention to disclose concussion symptoms (PR=1.39; p=0.08).

CONCLUSIONS

Concussion-related perceived social norms, attitudes, and perceived control are associated with intention to disclose. Organizationally appropriate intervention strategies can be developed from these data.

Demographic, Parental, and Personal Factors and Youth Athletes' Concussion-Related Knowledge and Beliefs

CONTEXT: 

Currently, significant attention is focused on improving care for patients with concussions through legislative mandates that include educational interventions. Few researchers have examined young athletes' concussion knowledge and the factors that may influence their knowledge.

OBJECTIVE: 

To use the socioecological model to examine demographic, parental, and personal factors associated with youth athletes' knowledge of concussion. Our ultimate goal is to inform the planning and implementation of youth sport concussion-related interventions.

DESIGN: 

Cross-sectional survey.

SETTING: 

Gymnasium and classroom.

PATIENTS OR OTHER PARTICIPANTS: 

North Carolina and Arizona youth athletes (n = 225; age = 8 to 15 years) active in football, boys' or girls' soccer, boys' or girls' ice hockey, or boys' or girls' lacrosse in 2012-2013.

MAIN OUTCOME MEASURE(S): 

Participants completed a validated, self-administered survey. The intention and belief measures were guided by the theory of planned behavior. Perceptions of concussion and intention to seek care were examined using descriptive statistics. Athletes' concussion knowledge was modeled using linear regressions and generalized estimating equations, with child demographic and personal factors and parental knowledge and attitudes about concussion as predictors.

RESULTS: 

Geography, sport, parental attitudes toward concussion, and athlete age were associated with athlete knowledge in the univariable analyses ( P < .10). In the multivariable model, geographic location (North Carolina versus Arizona, mean difference [MD] = 2.2, 95% confidence interval [CI] = 1.1, 3.2), sport (girls' soccer versus girls' lacrosse, MD = 2.2, 95% CI = 0.7, 3.6), more favorable parental attitudes toward concussion (MD = 1.2 for a 2-standard deviation shift; 95% CI = 0.3, 2.1), and older age (>12 years, MD = 1.6; 95% CI = 0.5, 2.6) were associated with better knowledge about concussion.

CONCLUSIONS: 

Geographic location, sport, parental attitudes about concussion, and athlete's age influenced athletes' concussion-related perceptions, indicating the need to address multiple levels of the socioecological model when targeting youth sport interventions. Parental interventions that translate to an improved culture of youth sport by improving youth athletes' perceptions and experiences are key areas for future work.

Using opinion leaders to address intervention gaps in concussion prevention in youth sports: key concepts and foundational theory

Behavioral interventions to increase disclosure and proper management of concussion in youth sports have unrealized potential when it comes to preventing concussion. Interventions have focused on changing individual athlete behavior and have fallen short of the potential for sustained systemic behavioral change. One potentially critical reason for this shortfall is that other key determinants of risk behaviors at all levels of the socio-ecological model (e.g. interpersonal, community, policy) are not addressed in extant programming. There is a critical need for theory-driven interventions that address concussion prevention and education at the community level and target sustainable culture change. The Popular Opinion Leader (POL) intervention, a multi-level intervention model previously successfully employed in multiple public health contexts, is theoretically well positioned to affect such change. POL is based on the Diffusion of Innovations framework and involves identifying, recruiting, and training well-respected and trusted individuals to personally endorse prevention and risk-reduction within their social networks. Critical behavioral changes related to concussion disclosure and management have been shown to diffuse to others if enough opinion leaders endorse and support the behaviors. This article summarizes the concepts and principles of POL and describes how it could be adapted for and implemented in youth sport settings. For optimal impact, POL needs to adapt to several factors unique to youth sports settings and culture. First, adult involvement may be important, given their direct involvement in the athlete's medical care. However, parents and coaches' opinions on injury care-seeking, competition, and safety may affect their perceptions of POL. Second, youth sports are structured settings both physically and socioculturally. Games and practices may provide opportunities for the informal interactions that are critical to the success of POL. However, youth sport setting membership is transient as players get older and move to other sport settings; POL approaches need to be self-sustaining despite this turnover. Moreover, stakeholder value placed on athlete development and competition, alongside safety, must be considered. Formative research is needed to ensure that POL principles are translated into the youth sport setting while maintaining fidelity to the concepts and principles that have made POL successful for other health outcomes.

Pediatric Traumatic Brain Injury and Concussion

PURPOSE OF REVIEW

This article summarizes the impact and complications of mild traumatic brain injury and concussion in children and outlines the recent evidence for its assessment and early management. Useful evidence-based management strategies are provided for children who have a typical recovery following concussion as well as for those who have persistent postconcussion syndrome. Cases are used to demonstrate the commonly encountered pathologies of headache, cognitive issues, and mood disturbances following injury.

RECENT FINDINGS

A clinical risk score using risk factors for poor recovery (eg, female sex, adolescence, previous migraine, and a high degree of acute symptoms) can be used to help the clinician plan follow-up in the community. Prolonged periods of physical and cognitive rest should be avoided. Multidisciplinary treatment plans are often required in the management of persistent postconcussion syndrome.

SUMMARY

A paucity of research exists for the treatment of postconcussion syndrome. Current treatments target individual symptoms.

Changes in Self-Reported Concussion History after Administration of a Novel Concussion History Questionnaire in Collegiate Recreational Student-Athletes

Research has shown that exposure to a concussion definition (CD) increases self-reported concussion history (SRCH) immediately, however, no research has been performed that examines the effects of exposure to a CD on SRCH over time. Collegiate recreational student-athletes (RSAs) have limited access to monitoring and supervision by medical staff. As such, recognition of concussion symptoms and need for medical management oftentimes falls upon the RSA. The purpose of this study was to assess the effect of a novel questionnaire on the SRCH of RSAs. A two-part questionnaire was sent to RSAs participating is sports with a greater than average risk of concussion at a university in Arizona. Data from 171 RSAs were analyzed to assess the change in RSAs' suspected concussion estimates pre- and post-exposure to a CD and concussion symptom worksheet, as well as over the short-term (2.5 months). Approximately one-third of RSAs reported an increase in suspected concussion estimates immediately following exposure to the questionnaire, but the change was not maintained over the short-term. The results suggest that a single exposure to a CD is ineffective at increasing short-term SRCH estimates.

Parents' and Child's Concussion History as Predictors of Parental Attitudes and Knowledge of Concussion Recognition and Response

Background:

Parents’ knowledge of and attitudes toward concussions are often vital factors that affect care for injured adolescent athletes. It is important to understand the role that parents’ personal experiences with concussions play with regard to current concussion knowledge and attitudes so that clinicians may tailor their educational approaches.

Purpose/Hypothesis:

The purpose of this study was to determine an association between parents’ personal experiences and their child’s experiences with concussions as well as parental concussion knowledge and attitudes. We hypothesized that parents who have personally experienced symptoms or have a child who has experienced symptoms would have better knowledge and more favorable attitudes toward concussions.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Parents of youth sport athletes (N = 234 [82 male, 144 female, 8 unreported]; mean age, 44.0 ± 6.3 years) completed a prevalidated survey for concussion knowledge (maximum score possible, 29) and attitudes (maximum score possible, 49). Higher scores indicated better knowledge and more favorable attitudes toward concussive injuries. Parents reported the frequency of concussion diagnoses and/or experiences of concussion-related symptoms and whether their child had suffered a diagnosed concussion or experienced concussion symptoms (yes/no). Spearman rank correlation and multivariable regression were used to examine the association between experience of symptom clusters (self or child) and concussion knowledge and attitudes.

Results:

Knowledge was moderate (mean, 23.3 ± 2.5 of 29), while attitudes prioritized disclosure (mean, 46.3 ± 3.7 of 49). Parents’ experience of the sleep-arousal symptom cluster was positively associated with concussion attitudes (r = 0.22, P = .002; β = –3.301, P = .011). Parents with children who experienced sleep-arousal and vestibular-somatic symptom clusters were weakly associated with parental concussion knowledge (sleep-arousal: r = 0.15, P = .041; vestibular-somatic: r = 0.17, P = .020; β = 0.540, P = .012).

Conclusion:

Our findings suggest that parents’ personal experiences with concussion-related symptoms have little effect on parental knowledge and attitudes as a whole. However, clinicians should consider particular symptom clusters that may provide insight into targets for future concussion education. According to these findings, parents of youth sport participants would benefit from increased concussion education focusing on the types of symptoms as well as the consequences of suffering a concussion.

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.