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Coaches: Improve Concussion Safety By Creating Safe Environment For Athlete Self-Reporting

Strongest influence on athletes' attitudes on concussion reporting, studies says

Creating safe concussion reporting environment

In addition, though, because they recognized that "knowledge alone does not equal behavior," and that "individuals may understand and believe that concussion is a serious injury and even a medical concern" but they may still not report the injury "if they also believe that their peers or coaches will take issue with their reporting their injury or that they may lose substantial playing time," Register-Mihalik and her colleagues also called for steps to be taken to "create an environment that rewards positive concussion-care seeking behaviors such as reporting an injury or removing one's self from play when experiencing concussive symptoms."

They offered as examples of steps that might be taken to create a safe concussion reporting environment having the athletic director at the school bringing in medical providers from the community to talk about concussion, and a coach being understanding and supportive when an athlete reports concussive symptoms and is unable to continue playing, especially in front of other athletes."  In addition, "parents play a key role in driving coaches to be aware and to create this environment at home," Register-Mihalik said in an interview with MomsTEAM's Lindsey Barton Straus. 

Concussion education of coaches and the creation of a safe reporting environment,  said the concussion reporting study, is particularly important given the role the coach often plays in initiating medical care in the event an athlete is injured; the fact that, while coaches do not have the same training as medical professionals and reporting to a coach is admittedly very different from reporting to a medical professional, coaches are often the authority figure to whom individuals turn to report a concussion or other injury; and the reality that less than half of all U.S. high schools have access to a certified athletic trainer.

Attitude adjustment

As Register-Mihalik wrote in the attitude study,[1] "the coach-athlete is unique as the coach has a large amount of control over athlete participation in games/practices.  Given that losing participation is a deterrent to reporting, it is logical to expect [those, like coaches, teammates, and parents] who influence participation to have some influence on concussion reporting among athletes."

"Conforming to a coach's belief system on the athletic field," she notes, "is common among athletes."  That a recent study suggested that coach listening and support may play a role in recovery from injury, Register-Mihalik argued, highlighted further the importance of coach opinion and support.

The "pivotal" and often decisive role a coach plays in influencing concussion reporting behavior was earlier highlighted in a 2013 focus group study by researchers at Seattle Children's Hospital and the University of Washington,[13] which found that:

Unless the coach made it clear that an athlete needed to report symptoms of concussion, it was perceived as unacceptable to come out because of a 'headache' or 'dizziness.' Athletes did not want to be wrong about being concussed and suffer negative consequences.  The coach could punish them for reporting concussive symptoms by removing them from a starting position, reducing future play time, or inferring that reporting concussive symptoms made them 'weak.' Coaches thus had an important role in facilitating concussive symptom reporting.  Athletes relied on their coaches for guidance regarding which symptoms to report and whether it was acceptable to stop playing.

Another 2013 study, this one assessing the effectiveness of the NCAA general concussion education mandate among Division 1 male hockey players [17] likewise found that concussion education which simply focused on educating athletes about concussion symptoms was ineffective, because it did not address what is increasingly seen by concussion experts as the root cause of underreporting: the negative attitude of coaches towards concussion symptom reporting by players.  

"The ineffectiveness of the existing educational materials in changing relevant [attitudes], and the low rate of recall for many modes of delivery [of concussion information] is not surprising given the didactic focus on symptom identification and reporting," writes lead author Emily Kroshus of the Department of Social and Behavioral Sciences at the Harvard School of Public Health.

Such focus, she wrote, "may be constraining concussion education effectiveness in changing reporting intention and behavior.  The importance of targeting cognitions other than just concussion identification is reinforced by the largely volitional reasons given by participants ... who believe that they sustained a concussion during the previous season but did not report it." 

Kroshus and her colleagues viewed their "findings of a significant association among knowledge, attitude and subjective norms and concussion reporting intention [as] reinforc[ing] the importance of these cognitions as targets of concussion education," and as further support for consideration, when designing programs to modify concussion reporting behavior, not just of player attitudes towards reporting, but what they perceive to be reporting norms and attitudes towards reporting by others, as recommended by Chrisman in her earlier 2013 study.[13]  

What coaches need to do

So what steps need to be taken so that a youth sports coach becomes part of the concussion solution, instead of continuing to be part of the problem?

Here are what the experts say needs to happen:

1. Prevention. Coaches need to learn and teach players a "heads-up" approach to sports by:

  • teaching proper tackling technique in football: A recent NATA study shows that high school football players are at greater risk for concussive events in part because they haven't learned proper tackling technique; a controversial 2013 study [6] also points to the need to teach younger players proper tackling, arguing that reducing the amount of time spent in full-contact drills during practice may lead to more concussions during games, but a subsequent study [14] found that the amount of contact during practices - as has been mandated by Pop Warner - does not result in higher impact exposure during games.
    • Teaching proper tackling at levels, from Pop Warner to high school, might eliminate up to half of football concussions, believes coach Bobby Hosea, who teaches a tackling technique called "Dip n' Rip" in which a football defender stops the ball carrier with an upward thrust across the chest and shoulders, not by leading with his helmet;
    • Rosemarie Scolaro Moser, Ph.D., sports neuropsychologist, founder of the Sports Concussion Center of New Jersey, and a MomsTeam expert, agrees. "A big consideration in all high risk sports is that at whatever age the youth transitions to contact or collision, whether 12, 14, 16, or 18 years of age, youth athletes will need to be trained to engage in safe, proper contact," she says. "Otherwise, lack of a proper program of training safe contact skill development will essentially defeat the purpose of setting an age designation. That means we will need educated coaches to teach safe and proper skill contact development in practices, so that when the youth athlete transitions to game contact, he or she will be ready, at any age.  [Both Coach Hosea and Dr. Moser are featured in MomsTEAM's PBS documentary about concussions, "The Smartest Team: Making High School Football Safer"]
  • teaching hockey players how to brace for and absorb body contact, as recommended by expert groups, like the American Academy of Pediatrics, as a way to reduce the risk of brain injury. As MomsTeam blogger and longtime Minnesota hockey coach and official, Hal Tearse, puts it, "Coaches need to do a better job of teaching players the right way to body check and how to absorb contact. It cannot be taught in a two-day clinic; it needs to be an important part of regular practices, and consistent messaging from coaches to players is required. The language we use needs to change, Instead of 'hit him', maybe words like "zero gap', 'take him', or 'box him/her out' might be better. Language is a funny thing in that words have power and meaning beyond what might be intended. Coaches need to choose their words carefully with young people."
2. Become educated about concussions, not just signs and symptoms, but sideline assessments, and about the need to create a safe concussion reporting environment.  Increased concussion education of coaches is essential. [1,5,10,13] 
  • Learn about the signs and symptoms of concussion.  Coaches need to know the signs and symptoms of concussion, so that, in the event there is no certified athletic trainer on the sideline (as is the case in at least 40% of U.S. high schools and in the vast majority of youth and middle school sports contests), they can remove a player from the game in order to for a sideline assessment.
  • Know how to conduct a brief sideline assessment. In the event no athletic trainer, team doctor, or other trained health care professional is on the sideline, coaches need to at least know how to conduct a brief, removal-from-play concussion assessment. There are a variety of courses coaches can take to learn about concussions, including free on-line course developed by the National Federation of State High School Associations in cooperation with the Centers for Disease Control and Prevention (CDC), in which coaches can learn how to recognize a suspected concussion, the proper protocols to manage a suspected concussion, and steps to help players return to play safely after experiencing a concussion, and the CDC's own "Heads Up" concussion kit for coaches.
  • Coaches need to understand the importance of reporting concussion.  The finding of two 2013 studies - one quantitative (data obtained from a large group of athletes answering questionnaires)[1] and the other qualitative (e.g. evaluating athletes' responses to questions and hypotheticals in focus groups)[13] show that coaches, along with teammates and parents, strongly influence concussion reporting behavior. 
    • Their findings "illustrate the need for educational programmes targeting [these] ... groups," says the author of the quantitative study,[1] "to emphasize the importance of reporting possible concussion."
    • "Given the coach's pivotal role in ... determining whether athletes reported concussive symptoms, interventions could be designed that focus on coach facilitation of symptom reporting," writes Sarah P. Chrisman, M.D., M.P.H., lead author of a 2013 focus group study which identified the attitude of coaches as the most significant barrier to concussive symptom reporting.[13]  
    • Chrisman noted that while some concussion laws require concussion education of coaches (a review conducted by a Temple University law school professor of the 45 concussion laws in place by the end of 2012 [15] - a number that has since risen to 48 plus D.C. - found that only 25 explicitly require coach education in recognizing the symptoms of concussion and traumatic brain injury (TBI) in youth sports), "such education is designed to increase concussion knowledge, not to increase the likelihood that athletes will report symptoms." (emphasis supplied).
    • While a 2010 study [10] found that 38% of coaches who ordered the CDC "Heads Up" concussion kit made changes in their prevention and management strategies, the fact that Chrisman's focus groups found coach's attittudes to be the biggest barrier to concussive reporting fully a year after Washington State's groundbreaking Lystedt Law went to effect requiring concussion education of coaches, illustrated, she said, the need for a different kind of coach education to "address communication with athletes regarding when and how to report symptoms, protocols for athlete assessment, and ... to improve approachability." That such education can help has been reported in a number of studies.
  • Coaches need to create a safe concussion reporting environment by:
    • Actively, consistently and repeatedly encouraging honest self-reporting by athletes of post-concussion signs and symptoms, both their own and those of their teammates (such as by employing the same kind of buddy system football programs often employ to protect athletes from heat illness during hot weather practices and games).
      • Athletes in the 2013 concussion attitude study [5] reported moderate agreement with the statement that "I expect my coach to place a lot of pressure on me," and "people who are important to me think I should not report."
      • Similarly, many athletes in the 2013 focus group study [13] reported receiving negative messages from coaches about injury reporting, with one football player saying that his coach told him that if had to come out on the field to take him off, "there better be a bone sticking out."
    • Reassuring athletes that they will not jeopardize their position as a starter or place on the team if they self-report, that the coaching staff will not question their toughness, call them "wimps" or "sissies," or ostracize them;
    • Informing players that deliberate hits to another player's head will subject them to disciplinary action; and
    • Advising athletes that they will be considered in violation of team rules, subjecting them to possible discipline - from game suspensions up to and including disqualification for the season - if they are found to have impeded appropriate evaluation and management of their own concussion by:
      • failing to report or under-report symptoms (theirs or a fellow player's);
      • intentionally underperforming on baseline neuropsychological tests in order to maximize chances of being cleared to play even with symptoms; or
      • indicating they are symptom-free so that they can be cleared to play in the next game when they are actually continuing to experience symptoms.
  • State concussion laws need to be strengthened to penalize coaches who fail to create a safe concussion reporting environment and knowingly allow or encourage players to continue playing with concussion symptoms.
    • Currently, only Pennsylvania and Connecticut penalize coaches for failing to remove a player with signs or symptoms of concussion or who allow a player to return to play without medical clearance in violation of their concussion safety laws, with the Keystone State requiring suspension for remainder of season for the first violation, suspension for remainder of the season and next season for a second offense, and, permanent suspension from coaching for a third violation, and the Board of Education in Connecticut empowered to revoke the license of a coach who violates the removal and return to play mandates.
    • Some recommend going even further. As Coach Bobby Hosea told a group of high school players during the filming of "The Smartest Team," coaches "need to put safety first. If they don't, they should not be allowed to coach. Period. Not suspended for the season. Barred from coaching for life."

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