High School Athletes' Perceptions of Concussion

A grounded theory of youth athlete concussion under-reporting decisions

BACKGROUND

Sport-related concussions leave youth vulnerable to significant health, physical, social, and educational disruptions. Many youth athletes under-report concussions, but the scope of the issue for this population is not well understood, nor are the underlying motivations for (under)reporting. It is necessary to examine the relationship between sport-related concussion knowledge and reporting and invite athletes to share their decision-making processes. The purpose of the research was to understand how athletes' attitudes, experiences and beliefs regarding concussions influence their under-reporting decisions and behaviours.

METHODS

We conducted semi-structured interviews with 17 elite athletes, aged 16-18 years, from individual and team sports. Data were analyzed using constructivist grounded theory and a substantive theoretical model of sport-related concussion under-reporting was developed.

RESULTS

The model demonstrates personal, social, cultural, and biophysical processes that contribute to under-reporting decisions and identifies multiple interconnected processes that contribute to 'high-risk' situations of under-reporting. Youth athletes navigate various barriers and facilitators to under-reporting, including their own desire to play, perceived stigma, concussion sense-making, and social influences. Results suggest that under-reporting by youth athletes implicates a collective, rather than individual, responsibility.

CONCLUSIONS

A theoretical grounded model for youth sport-related concussion under-reporting highlights the complexity of the decision-making process. This study offers a new framework for understanding why youth athletes may hide concussion symptoms. The model offers potential to be used to develop concussion interventions and tools for improved decision-making, and to address issues of risk and responsibility concerning concussion reporting.

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.

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.

The influence of education in decision making concerning athlete’s return to sport following a concussion injury: A systematic review

Objectives

Concussions have emerged as one of the most prevalent and controversial injuries sustained within the sporting context. The objective of this review was to determine the influence that education has on decision making concerning athlete’s return to sport following a concussion injury and if the risk is worth it in the eyes of the athletes.

Study design

Systematic review.

Methods

A rapid literature review was performed in PubMed, CINAHL, SPORTDiscus, Embase and Web of Science looking for articles that discussed concussions and any three of the four following search terms: (a) decision making, (b) education/knowledge, (c) sport/return to sport and (d) risk.

Results

Sixteen of 1243 articles were included in this review based on eligibility criteria. Ten were cohort studies, four were cross-sectional studies and two were qualitative research. There was a good agreement between the authors for all studies when determining risk of bias, presenting a Cohen’s κ of 0.901 (95% CI, 0.834, 0.968), p <  0.001.

Conclusion

Education can make a difference in athlete’s decision making process to return to sport; however, their awareness of the health risks that they put themselves in by returning to sport too soon is clouded by other external and internal factors. What is not fully understood is why do they put themselves at this risk? Further studies should explore athletes’ risk aversion behaviour and how it impacts their decision to return to sport following a concussion.

Are Adolescent Climbers Aware of the Most Common Youth Climbing Injury and Safe Training Practices?

Finger growth plate injuries are the most common youth climbing injuries. The purpose of our study was to understand youth awareness of the most common youth climbing injury and safe training practices. We surveyed climbers, ages eight to 18 years old, at the 2017 USA Climbing Sport and Speed Youth National Championships. A total of 267 climbers completed the survey (mean age = 14 ± 2.7 years; 52% male). The A2 pulley injury was reported as the most common youth climbing injury by the largest portion of participants, 36%. The second most commonly identified injury was at the growth plate of the finger, 15% of participants, which was reported as significantly less than the A2 pulley injury, p < 0.001. Six percent of climbers reported the correct safe age to start double dyno campus board training. Roughly 18% of athletes identified growth plate injuries exclusively as a stress fracture, whereas 29.2% of those climbers self-reported as informed about finger growth plate injuries, but only 7.4% of climbers who self-reported as uninformed answered this question correctly. Misperceptions about skeletally-immature climbing injuries are prevalent amongst youth climbers. Education on the prevalence of finger growth plate injuries and the scarcity of A2 pulley injuries in youth climbers can increase diagnostic accuracy, improve care, and reduce long-term complications.

Parental knowledge of concussion: Evaluation of the CDC's "Heads up to parents" educational initiative

BACKGROUND

Potential negative outcomes associated with sport-related concussion drive the need for resources to educate parents about prevention, recognition, and management of concussion in the youth athlete. Parents play a critical role in the recognition and management of concussion for their child.

PURPOSE

This study aims to (a) investigate current knowledge of concussion among parents whose children age 5-18 years play a club sport and (b) identify effects of an online video versus online print educational intervention on concussion knowledge change and learning.

METHODS

140 parents whose children played a club sport answered questions regarding their knowledge of sport-related concussion pre- and post-random assignment to an educational intervention: CDC Concussion Awareness video or CDC Concussion Fact Sheet for Parents.

RESULTS

Participating parents demonstrated a moderate level of pre-intervention knowledge, but critical gaps in knowledge were identified. Knowledge of concussion improved slightly following intervention regardless of intervention type.

CONCLUSIONS

This study confirms the presence of gaps in knowledge of concussion in parents whose children play club sports. Without the protection of concussion legislation, those athletes who participate in club sports are at particular risk due to lack of concussion knowledge and education. This study confirms that education can have a positive impact on parental knowledge of concussion. Practical applications: Pre-knowledge of concussion is the greatest predictor of post-knowledge of concussion, therefore pre-assessment of target audience knowledge followed by a custom educational intervention taking into account principles of adult learning, would be the most beneficial to increasing concussion knowledge.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

Return to Learn After Sport-Related Concussion: A Survey of Secondary School and Collegiate Athletic Trainers

CONTEXT

Recent recommendations have emphasized return-to-learn (RTL) protocols to aid athletes in recovery from sport-related concussion (SRC) but have been based primarily on anecdotal evidence.

OBJECTIVE

To investigate the RTL practices of certified athletic trainers (ATs) after an SRC.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 1083 individuals (27%) from a random sample of 4000 ATs in the National Athletic Trainers' Association membership database completed an electronic survey. Participants consisted of 729 self-identified secondary school ATs (SSATs; 67.3%; experience = 14.0 ± 9.7 years) and 354 self-identified collegiate ATs (CATs; 32.7%; experience = 13.4 ± 9.7 years).

MAIN OUTCOME MEASURE(S)

We used χ² analyses to assess respondent differences related to current knowledge, current practices, and available resources. Independent t tests were used to compare SSATs and CATs on years of certification and annual number of SRCs evaluated.

RESULTS

Of our total respondents, 41.2% (n = 446) correctly indicated the absence of evidence-based RTL guidelines. Whereas most (73.9%, n = 800) respondents had an established RTL policy, only 38.1% (n = 413) used such guidelines in their clinical practice. Most (97.1%, n = 708) SSATs and 82.2% (n = 291) of CATs had access to (a) mental health professional(s); however, minorities of SSATs (21.4%, n = 156) and CATs (37.0%, n = 131) never accessed these resources to care for concussed student-athletes.

CONCLUSIONS

Our results suggested that, despite the absence of empirical evidence, most surveyed ATs incorporated some form of RTL protocol in their SRC management policy. The varying AT knowledge, clinical practices, and resources highlighted by our results should be considered when creating or refining an RTL protocol.

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

BACKGROUND/AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Age at First Concussion Influences the Number of Subsequent Concussions

BACKGROUND

Individuals who sustain their first concussion during childhood may be at greater risk of sustaining multiple concussions throughout their lifetime because of a longer window of vulnerability. This article aims to estimate the association between age at first concussion and number of subsequent concussions.

PATIENTS AND METHODS

A total of 23,582 collegiate athletes from 26 universities and military cadets from three military academies completed a concussion history questionnaire (65% males, age 19.9 ± 1.4 years). Participants self-reported concussions and age at time of each injury. Participants with a history of concussion (n = 3,647, 15.5%) were categorized as having sustained their first concussion during childhood (less than ten years old) or adolescence (≥10 and ≤18 years old). Poisson regression was used to model age group (childhood, adolescence) predicting the number of subsequent concussions (0, 1, 2+). A second Poisson regression was developed to determine whether age at first concussion predicted the number of subsequent concussions.

RESULTS

Participants self-reporting their first concussion during childhood had an increased risk of subsequent concussions (rate ratio = 2.19, 95% confidence interval: 1.82, 2.64) compared with participants self-reporting their first concussion during adolescence. For every one-year increase in age at first concussion, we observed a 16% reduction in the risk of subsequent concussion (rate ratio = 0.84, 95% confidence interval: 0.82, 0.86).

CONCLUSIONS

Individuals self-reporting a concussion at a young age sustained a higher number of concussions before age 18. Concussion prevention, recognition, and reporting strategies are of particular need at the youth level.

Concussions in NCAA Varsity Football Athletes: A Qualitative Investigation of Player Perception and Return to Sport

Background

The objective of this study was to understand the experiences and perspectives of varsity football athletes on return to play following a concussion injury.

Methods

Two experienced interviewers conducted qualitative, semistructured interviews of college-level football players who had sustained at least one concussion during their varsity careers.

Results

Twenty varsity football players who averaged 2.3 concussions each (range, 1-5) were interviewed regarding peer pressure, the culture of football, and player awareness as factors affecting return to sport following a concussion. Less common secondary factors included risk management, severity and timing of the injury, and team support.

Conclusions

Psychological stressors, the culture of football, and increased awareness were the most influential factors affecting collegiate football players' deciding to return to sport following a concussion.

Level of Evidence

Level III.

Twitter and traumatic brain injury: A content and sentiment analysis of tweets pertaining to sport-related brain injury

Objectives:

Sport-related traumatic brain injuries are a significant public health burden, with hundreds of thousands sustained annually in North America. While sports offer numerous physical and social health benefits, traumatic brain injuries such as concussion can seriously impact a player’s life, athletic career, and sport enjoyment. The culture in many sports encourages winning at all costs, placing athletes at risk for traumatic brain injuries. As social media has become a central part of everyday life, the content of users’ messages often reflects the prevailing culture related to a particular event or health issue.

Methods:

We hypothesized that Twitter data might be useful for understanding public perceptions and misperceptions of sport-related traumatic brain injuries. We performed a content and sentiment analysis of 7483 Twitter^® tweets related to traumatic brain injuries in sports collected during June and July 2013.

Results:

We identified five major themes. Users tweeted about personal traumatic brain injuries experiences, reported traumatic brain injuries in professional athletes, shared research about sport-related concussions, and discussed policy and safety in injury prevention, such as helmet use. We identified mixed perceptions of and sentiment toward traumatic brain injuries in sports: both an understanding that brain injuries are serious and disregard for activities that might reduce the public burden of traumatic brain injuries were prevalent in our Twitter analysis.

Conclusion:

While the scientific and medical community considers a concussion a form of traumatic brain injuries, our study demonstrates a misunderstanding of this fact among the public. In our current digital age, social media can provide useful insight into the culture around a health issue, facilitating implementation of prevention and treatment strategies.

Epidemiology of Sport-Related Concussions in High School Athletes: National Athletic Treatment, Injury and Outcomes Network (NATION), 2011-2012 Through 2013-2014

CONTEXT

Sports participation is one of the leading causes of concussions among nearly 8 million US high school student-athletes.

OBJECTIVE

To describe the epidemiology of sport-related concussion (SRC) in 27 high school sports during the 2011-2012 through 2013-2014 academic years.

DESIGN

Descriptive epidemiology study.

SETTING

Aggregate injury and exposure data from 27 sports in 147 high schools in the National Athletic Treatment, Injury and Outcomes Network (NATION).

PATIENTS OR OTHER PARTICIPANTS

Boy and girl high school athletes during the 2011-2012 through 2013-2014 academic years.

MAIN OUTCOME MEASURE(S)

Sport-related concussion counts, percentages, rates per 10 000 athlete-exposures (AEs), rate ratios (RRs), and injury proportion ratios (IPRs) were reported with 95% confidence intervals (CIs). Rate ratios and IPRs with 95% CIs not containing 1.0 were considered significant.

RESULTS

Overall, 2004 SRCs were reported among 27 high school sports, for a rate of 3.89 per 10 000 AEs. Football had the highest SRC rate (9.21/10 000 AEs), followed by boys' lacrosse (6.65/10 000 AEs) and girls' soccer (6.11/10 000 AEs). The SRC rate was higher in competition than in practice (RR = 3.30; 95% CI = 3.02, 3.60). Among sex-comparable sports, the SRC rate was higher in girls than in boys (RR = 1.56; 95% CI = 1.34, 1.81); however, the proportion of SRCs due to player-to-player contact was higher in boys than in girls (IPR = 1.48; 95% CI = 1.27, 1.73). Common symptoms reported among all athletes with SRCs were headache (94.7%), dizziness (74.8%), and difficulty concentrating (61.0%). Only 0.8% of players with SRCs returned to play within 24 hours. The majority of athletes with SRCs (65.8%) returned to play between 7 and 28 days. More players had symptoms resolve after 7 days (48.8%) than less than a week (40.7%).

CONCLUSIONS

Our findings provide updated high school SRC incidence estimates and further evidence of sex differences in reported SRCs. Few athletes with SRCs returned to play within 24 hours or a week. Most injured players returned after 7 days, despite a smaller proportion having symptoms resolve within a week.

Treatment Perspectives Based on Our Current Understanding of Concussion

Sports-related concussion also referred to in the literature as mild traumatic brain injury remains a popular area of study for physicians, neurologists, neuropsychologists, neuroimaging, athletic trainers, and researchers across the other areas of brain sciences. Treatment for concussion is an emerging area of focus with investigators seeking to improve outcomes and protect patients from the deleterious short-term and long-term consequences which have been extensively studied and identified. Broadly, current treatment strategies for athletes recovering from concussion have remained largely unchanged since early 2000s. Knowledge of the complex pathophysiology surrounding injury should improve or advance our ability to identify processes which may serve as targets for therapeutic intervention. Clinicians working with athletes recovering from sports-related concussion should have an advanced understanding of the injury cascade and also be aware of the current efforts within the research to treat concussion. In addition, how clinicians use the word "treatment" should be carefully defined and promoted so the patient is aware of the level of intervention and what stage of recovery or healing is being affected by a specific intervention. The purpose of this review is to bring together efforts across disciplines of brain science into 1 platform where clinicians can assimilate this information before making best practices decisions regarding the treatment of patients and athletes under their care.