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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

Culture club

In the final analysis, argues Echlin, the author of the 2012 Canadian study on concussion reporting and attitudes in boy's hockey,[2] "A change in the culture of sports concerning the seriousness of brain injury is fundamental to reducing the incidence of this type of injury, and to improved identification and treatment."

The challenge is a daunting one, Echlin observes, because there is a "social resistance to change concerning concussion identification and treatment" (or what a 2014 Institute of Medicine/National Research Council report [19] on concussions referred to as a "culture of resistance") which will hard to overcome, even with significant efforts to educate teams and improve their care."  

Register-Mihalik struck a slightly more optimistic tone: "We are certainly seeing changes at many levels of sport in the right direction, but still have a long way to go." Register-Mihalik told MomsTEAM. 

"I do think there are things we can continue to do in the here and now that will result in immediate effects, especially when local individuals are advocates for concussion education and sport safety. However, it is true that historically culture change does take years."

"One approach ... is to start at the youngest ages of sport so that individuals carry good attitudes about sports safety and concussion throughout their lives. It is also important that, in addition to this bottom up approach, that we have things trickle down from the top so that information is flowing in both directions, creating a more comprehensive safety network across sport."

"Now that we have many people attentive to concussion, we need to make sure the right message is getting to the right people, in communities of all types. This involves community networking including parents, coaches, administrators and medical professionals at the local, state, regional and national levels working together," Register-Mihalik concluded.

"New coach education might address communication with athletes regarding when and how to report symptoms, protocols for athlete assessment, and general approachability," recommends Chrisman. [13]

For their part, the authors of a 2013 study [17] assessing the effectiveness of the NCAA's general concussion education mandate, said what was needed, "more than the bare minimum of passing out a symptom sheet and saying a few words," was for a team's coaches and medical staff to "foster a culture of safety and reporting through other formal and/or informal means, and for evaluation efforts to "simultaneously assess coach and team medical personnel knowledge, attitudes and communication with athletes about concussions and determine how factors related to coach and medical staff [vary] with education content, delivery and effectiveness."

The Institute of Medicine committee responsible for the IOC's 2014 report on sport-related concussion [19] was encouraged by the Chrisman [14] and two Register-Mihalik studies [1,5] finding that greater athlete knowledge about concussions and more favorable attitude toward reporting possible concussion was associated with increased reporting prevalence of concussion and "bell-ringer" events in these youth.  At the same time, it recognized that "reporting intention may not always be an indicator of what an individual's actual concussion reporting behaviors will be," citing the three studies as suggesting that "future concussion education initiatives should focus on improving attitudes and beliefs about concussions among athletes, coaches, and parents."


1.  Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives. Brain Injury 2013;27(7-8):878-886.

2. Echlin PS, Editorial. A prospective study of physician-observed concussion during a varsity university ice hockey season. Part 1 of 4. Neurosurg Focus 2012;33(6):E1 (published online ahead of print)(accessed December 10, 2012).

3. Valovich-McLeod TC, Schwartz C, Bay RC.  Sport-related concussion misunderstanding among youth coaches.  Clin J Sport Med.  2007;17(2):140-142.

4. Mickalide AD, Hansen LM. Coaching Our Kids to Fewer Injuries: A Report on Youth Sports Safety. Washington, DC: Safe Kids Worldwide, April 2012 

5.  Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW.  Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study.  J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)

6.  Kontos P, Fazio V, Burkart S, Swindell H, Marron J, Collins M. Incidence of Sport-Related Concussion among Youth Football Players Aged 8-12 Years. J Pediatrics 2013. DOI 10.1016/j.jpeds.2013.04.011

7.  Meehan WP, III, Kids,Sports, and Concussions. (Praeger 2011), p. 118-20.

8.  Cohen M. "Neck strengthening exercises could help lessen risk of concussions." Sports Illustrated (September 28, 2012)(http://sportsillustrated.cnn.com/2012/football/ncaa/09/28/concussions-neck-strength-syracuse-eastern-michigan/index.html)(accesssed February 22, 2013).

9.  Gregory S. "Neck Strength Predicts Concussion Risk, Study Says" (http://keepingscore.blogs.time.com/2013/02/21/study-neck-strength-predic...)(accessed February 22, 2013), citing Comstock R.D. High School Sports-Related Injury: Recent Trends and Research Findings. Presented at the National Youth Sports Safety Summit, Washington, D.C., February 5, 2013. 

10. Sarmiento K, Mitchko J, Klein C, Wong S. Evaluation of the Centers for Disease Control and Prevention's concussion initiative for high school coaches: "Heads Up: concussion in high school sports."  J Sch Health 2010;80(3):112-118.  4.1. Meehan WP, Kids, Sports, and Concussion (Praeger 2011)  

13. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.

14. Cobb BR, Urban JE, Davenport EM, Rowson S, Duma SM, Maldjian JA, Whitlow CT, Powers AK, Stizel JD. Head Impact Exposure in Youth Football: Elementary School Ages 9-12 Years and the Effect of Practice Structure. Ann Biomed Eng ( 2013): DOI: 10.1007/s10439-013-0867-6 (online ahead of print).

15. Harvey HH. Reducing Traumatic Brain Injuries in Youth Sports: Youth Sports Traumatic Brain Injury State Laws, January 2009-December 2012.  Am J Pub Health 2013; doi:10.2105/AJPH.2012.301107 (epub May 16, 2013)

17. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)

18.  Delaney JS, Lamfookon C, Bloom GA, Al-Kashmiri A, Correa JA.  Why University Athletes Choose Not To Reveal Their Concussion Symptoms During A Practice Or Game.  Clin J Sports Med. 2014;0:1-13; doi: 10.1097/JSM.0000000000000112 (published online ahead of print with post-publication corrections, June 19, 2014).

19. Institute of Medicine (IOM) and National Research Council (NRC). 2013. Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press

Most recently revised and updated September 6, 2014 with the invaluable assistance of MomsTEAM Senior Health & Safety Editor, Lindsey Barton Straus, JD.
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