Question: Why don't athletes report experiencing concussion symptoms?
Answer: For a number of reasons.
Some athletes don't report because they don't know what the symptoms are, or because the concussions they have suffered adversely affect their judgment and cognition, so, even if they do know the symptoms, they don't recognize that they are experiencing them.
Unfortunately, most don't report because a deeply engrained culture in contact of contact and collision sports tells them not to; they don't report because they don't want to disappoint teammates, coaches, and parents by removing themselves from the game; or they fear losing playing time or their starting position.
The laws of all but a few states now mandate that athletes with suspected concussion not only be removed from the game or practice in which they are participating, but not permitted to return that same day, and obtain written authorization to return to play from a health care professional with expertise in the identification, diagnosis, and management of concussion. The laws, some experts fear, make athletes even less willing to report experiencing concussion symptoms because they know that, if they do, they will be benched.
Question: Why, then, isn't the answer to the chronic under-reporting of concussions to educate athletes about the symptoms of concussion and the dangers of continuing to play with such symptoms? Isn't that the law now in almost all states?
Answer: Yes, it is true that 47 of 50 states have passed laws requiring that athletes and their parents sign forms acknowledging receipt of information about concussion signs and symptoms and the dangers of continuing to play with concussion. Unfortunately, however, recent studies suggest that, education of athletes about the symptoms of concussion and the dangers of continuing to play with such symptoms, has not resulted in increased reporting, with athletes continuing to resist honestly self-reporting experiencing symptoms or voluntarily removing themselves from game action. (what a new report from the Institute for Medicine and the National Research Council terms a "culture of resistance.")
The same studies suggest that athletes may be more likely to self-report if they feel safe in self-reporting, in other words, when they don't fear adverse repercussions if they report in terms of decreased playing time, losing their starting positions, or being embarrassed by the coach in front of their teammates for their lack of toughness, such as, for example, by being labeled a "wimp" (or worse).
This has led an increasing number of experts to recommend that concussion education should be as much about removing the stigma associated with reporting and changing the attitudes of players, coaches, and parents towards reporting as it is about educating them about concussion signs and symptoms.
The problem is that no such programs yet exist, and even if they did, and were implemented on a widespread basis, it is unclear whether such a shift in emphasis in concussion education would achieve any meaningful increase in rates of self-reporting. The reason, again, is that it would not only require a paradigm shift in the "warrior" culture of contact and collision sports, but a fundamental change in a risk-taking attitude, which is a part of the very nature of adolescence.
Question: So if athletes won't report concussion symptoms, why can't we just rely on sideline personnel to watch for signs of concussion in athletes so they can be removed from play?
Answer: Relying on the observational skills of sideline personnel is problematic for a number of reasons. To begin with, the signs of concussion are often either subtle or non-existent, so they escape detection by sideline personnel. (Gone are the days when it took a player's loss of consciousness or heading to the wrong sideline or end zone to raise a red flag about possible concussion.) Many escape detection by even well-trained sideline personnel. (One Canadian study, for instance, found that physician observers in the stands identified concussed athletes at a rate seven times that of coaches and athletic trainers on the bench).
Add in the possibility that sideline personnel responsible for monitoring athletes for signs of concussion, such as team doctors and athletic trainers, may be away from the sideline attending to other injured athletes when a player sustains a high force blow, or, even if they are watching the field/court/rink, may miss significant impacts because they occur away from the play, and one can see why better concussion detection methods are needed.