As many as four out of ten of possible concussions sustained by high school athletes are never reported to a coach or medical professional, with only one in seven concussions considered 'bell-ringers' reported, finds a 2013 study. [1]
Researchers at WakeMed Health and Hospitals, Raleigh, NC, the University of North Carolina at Chapel Hill, and A.T. Still University in Mesa, Arizona found that, while athletes are generally knowledgeable about the signs and symptoms of concussion [1], there is a "gross underreporting" of concussion events, with a large proportion of those surveyed indicating that they continued to participate in both games and practices while experiencing symptoms.
"Most strikingly," writes Johna Register-Mihalik, Ph.D, LAT, ATC, Senior Research Associate at WakeMed and Adjunct Assistant Professor at UNC-Chapel Hill, "athletes only indicated reporting 13% of events they considered bell ringers, which were likely concussive injuries."
The concern, she writes, is that "athletes not reporting these bell-ringer events may have continued to participate or returned to participation too early, predisposing them to further injury."
"We were not overly surprised" by the low rate of reporting bell-ringer events, Register-Mihalik told MomsTEAM, because previous studies have shown that "terminology around concussion is an issue, [with] the terms 'bell ringer' and 'ding' having different meaning to various individuals. Certainly, the culture of the 'warrior mentality' plays a role in not reporting these events," she observed, "but some of it is also an awareness issue, and we have a great opportunity, with so much attention around concussion, to increase knowledge in this area.
One of our recommendations is that we remove these terms from the discussion of concussion so as to not minimize concussion as anything other than a brain injury [2]. All of these events are likely not concussions, but individuals should be aware enough to know that they should let someone know that a potential concussive event has occurred and move forward from that direction."
Tamara Valovich McLeod, , PhD, ATC, FNATA, Professor in the Athletic Training Program and Directors of the Interdisciplinary Research Laboratory, and Athletic Training Practice-Based Research Network in the Department of Interdisciplinary Health Sciences at A.T. Still University in Mesa, Arizona, noted that some of her previous work [6] had shown a higher rate of reporting when terms like "ding"and "bell-rung" were included. "We do need to educate that those events, even though they may seem inconsequential, need to be reported and evaluated by a healthcare provider. I'd rather err on the side of caution and remove a child to evaluate him/her than miss a concussion and have a catastrophic event."
Despite increased concussion education, the underreporting rate of approximately 40% for perceived concussions the researchers found was not substantially better than the 50% underreporting rate found in previous studies over the last decade. [2,3,4]
Although some studies have examined knowledge and attitude towards concussion [5,6,7], few quantitative studies have examined the influence of concussion knowledge on reporting frequency, and few prior studies have examined overall attitudes concerning concussion and reporting of possible concussion among high school athletes.
To test the hypothesis that better knowledge about concussions and attitudes towards reporting concussion symptoms are associated with higher rates of reporting, researchers surveyed 1669 high school athletes in 6 sports (football, cheerleading, boys' and girls' soccer, boys' or girls' lacrosse) at 25 U.S. high schools over the period November 2008 to February 2010 [before many of the so-called Lystedt laws [3] were passed by almost U.S. states requiring mandatory concussion education as a condition for sports participation]. To model the reality that less than 50% of U.S. high schools have access to an athletic trainer [4] [11] (recent statistics [5] [17] from the National Athletic Trainers' Association suggest that the percentage has ticked up to about 70%), 15 of the schools had daily access to an AT, while 10 did not.
167 14- to 18-year-old athletes (10% of the total) completed a 35-question survey testing their concussion symptom recognition, knowledge of complications related to multiple concussions, and general concussion knowledge (see chart below). Athlete attitude was assessed with 14 questions about overall attitude towards concussion, concussion education, and concussion reporting on a 7-point scale, with 1 signifying no agreement and 7 indicating complete agreement (see chart)
To assess recalled concussion events and reporting during high school, athletes were asked how many concussions they think they had experienced during high school, how many of the possible concussions they reported to medical professional or coach, and, as a way of assessing when possible concussion occurred, were also asked how many times they had their 'bell rung' or had been 'dinged.' Because the study was based on personal perceptions, no definition of the term 'bell ringer' was given, but the term is commonly used to describe brief, transient alterations in neurololgic function, not all of which may have been true concussions but which warranted examination before an athlete should be allowed to return to play. Finally, athletes were asked about their reporting behaviors, and why they had not reported possible concussion or bell-ringer events.
Consistent with a 2004 study [2], the study found that athletes did not report possible concussions because they:
By comparison, among college hockey players in a 2013 study [12] who suspected that they had a concussion during the previous season but did not report their injury:
The data revealed a wide range of attitudes about concussion. Athletes indicated only moderate agreement with the statement on the questionnaire that concussion symptoms were serious, and many believed reporting concussions may be somewhat embarrassing. "Downplaying concussion symptoms and feelings of embarrassment about reporting them illustrate some of the attitudes towards concussion that need attention," wrote Register-Mihalik.
While the low reporting rate was disappointing, especially given the concentrated effort in recent years to educate youth and high school athletes about the dangers of concussions, the good news in the study was that, in general, improved athlete knowledge positively affected their willingness to report, with the proportion of those reporting bell-ringer events, and of concussive events during practice, greater with increased athlete knowledge.
Athlete attitude also had positive overall effects on reporting behaviors, researchers found, with higher scores associated with a decrease in athletes reporting that they participated in a game or practice while symptomatic. Register-Mihalik and her colleagues speculated that athletes with a more favorable attitude toward reporting were those with a better understanding of the importance of reporting possible concussion events.
Recognizing that underreporting of concussion is a "multifaceted" and "overwhelming" problem, with knowledge and attitude both appearing to influence reporting behaviors, the study authors recommend taking a multi-pronged approach to improving reporting rates, including:
1. Increasing education about concussion symptoms.
Especially needed is education about less common symptoms, such as nausea (cited as a symptom by 31.4% of high school athletes [8]) and amnesia [6] (cited as a symptom in 23.4% of concussions in another recent study [9]). "These symptoms, as well as the other symptoms, should be emphasized in educational efforts," Register-Mihalik told MomsTEAM, "due to their connection with potential delayed recovery time [as both have been linked in a recent study [7] [8] with increased risk of prolonged symptoms], as well as the impact that these symptoms have on overall quality of life. [Because] nausea is often associated with other conditions [such as dehydration [8] or overeating before an event], helping young athletes connect this symptom to a potential concussive injury is also important. Amnesia is a difficult symptom, and many young athletes may not fully understand what amnesia as a term actually means, so using age-appropriate terminology when assessing and discussing concussion, such as 'trouble remembering things' or 'memory problems' may also be helpful."
Study co-author McLeod agreed that, while all concussion signs and symptoms should be discussed in educational efforts, "We probably could do a better job of educating about the immediate and most prevalent symptoms, but pay equal attention to those that occur less often, may be indicative of decline in [mental] status [9][which may indicate a more serious brain injury], and those that may be late manifesting so that concussions are not missed by just focusing on a few signs and symptoms. Identifying symptoms that might be predictive of delayed recovery or poorer prognosis [10] is one area of research that I believe will continue to emerge in the coming years;"
2. Fostering increased understanding among clinicians, parents, coaches, and athletes of:
3. Increasing education of coaches. Such education is especially needed in recognition of 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 fact that fewer than half of all U.S. high schools have access to a certified athletic trainer. [11] [Note: more recent data from the NATA [5] [17] suggest that the percentage now stands at over 60%].
4. Creating a safe environment which encourages reporting of concussion events by: [12]
"Clinicians, parents, and coaches should make concussion education and awareness a priority," concludes Register-Mihalik and her colleagues, "and address factors to provide a more optimal concussion-reporting environment." Both are needed, because, as acknowledged in the study, "knowledge alone does not equal behavior." "Individuals may understand and believe that concussion is a serious injury and even a medical concern; however, 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, they may still choose not to report the injury." "Parents also play a key role in driving coaches to be aware and to create this environment at home," Register-Mihalik told MomsTEAM.
Indeed, a 2014 study [15] provides support for Register-Mihalik's conclusions, finding that concussion knowledge was not significantly associated with in-season reporting behavior, and that a better predictor of in-season reporting behavior was intention to report symptoms of a minor concussion, with increasing odds of reporting as additional symptoms were sustained. The study's authors acknowledged, however, that it was possible that for some populations (eg, younger athletes aor athletes early in their sporting careers), concussion knowledge as it is presently measured may be an important predictor of reporting behavior.
Valovich McLeod agreed with Register-Mihalik that "There is promise to make these changes happen faster with educational efforts and legislation; however, there are still coaches and parents who have an old-school mentality regarding concussions. Pressure to play needs to be taken off kids in order for them to feel comfortable reporting their signs and symptoms of a possible concussion."
5. Future research to explore how external factors influence reporting among high school athletes, such as
"Although our study encompassed only 1 convenience sample of athletes, the major findings illustrated the importance of increased athlete knowledge, more favorable athlete attitude, and context of reporting concussion among high school athletes," wrote Register-Mihalik.
"We highlighted the importance of addressing multiple factors to increase reporting of possible concussive injuries. In addition, we highlighted the need for multifactorial interventions in the high school setting to address these risky behaviors."
"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.
Concussion Sign or Symptom? | % Answering Correctly |
Amnesia [6] | 56.3 |
Confusion | 92.2 |
Dizziness [15] | 88,6 |
Headache | 88.6 |
Insomnia | 83.8 |
Loss of consciousness [16] | 76.0 |
Nausea | 64.1 |
Numbness or tingling of arms |
67.1 |
General knowledge | |
A concussion only occurs if you lose consciousness (false) |
84.7 |
If you are experiencing any signs or symptoms of concussion [1] after a blow to head or sudden movement of the body, you should not return to play (true) |
|
A concussion is an injury to the ______ (brain) | 88.5 |
Multiple concussions: Of the following, what are the possible complications of having multiple concussions? (check all that apply) | |
No complications exist (false) |
100.0 |
Increased risk of further injury (true) | 63.5 |
Brain damage (true) |
91.0 |
Join problems (false) |
89.8 |
I don't know (false/not checked) |
94.0 |
Memory problems (true) | 85.0 |
Returning to play too soon: Of the following, what are complications of returning to sporting activity while still experiencing possible concussion symptoms? Check all that apply. | |
No complications (false) |
99.4 |
Increased risk of further injury (true) |
86.8 |
Paralysis (false) |
55.1 |
Brain damage (true) |
86.8 |
Joint problems (false) |
88.0 |
I don't know (false/not checked) | 92.0 |
Athlete Attitude
Rate on a scale of 1-7 |
Mean |
How serious you think it is when you experience a headache or dizziness after a blow to your head or body |
4.5 |
How important you think it is to not participate in physical activity (game or practice) when experiencing signs and symptoms of concussion. | 5.5 |
How important you think it is to be informed about how concussions happen | 5.9 |
How important you think it is to be informed about how concussions can be prevented |
5.9 |
How important it is to be informed about what to do if you have a concussion |
6.3 |
How important you think it is to report possible signs and symptoms to a medical professional (eg, doctor, athletic trainer) or coach | 6.1 |
Your level of agreement with the following statement: Athletes are undereducated about concussion | 5.1 |
Check the box (1-7) about how you feel about the following statement for each pair of words listed: For me to report possible signs and symptoms to a coach or a medical professional when I experience them is | |
Cowardly/brave | 5.1 |
Embarrasing/pleasant | 4.5 |
Harmful/beneficial |
6.2 |
Extremely difficult/extremely easy |
5.0 |
Bad/good |
6.0 |
Unimportant/Important |
6.1 |
Worthless/valuable |
6.1 |
Athlete attitude total |
78.3 |
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Most recently revised and updated April 30, 2016
Links:
[1] https://www.momsteam.com/node/149
[2] https://www.momsteam.com/node/2903
[3] https://www.momsteam.com/node/3015
[4] https://www.momsteam.com/node/190
[5] https://www.momsteam.com/access-athletic-trainers-doubles-in-20-years-but-thirty-percent-us-high-schools-still-provide-no-at-coverage
[6] https://www.momsteam.com/node/203
[7] https://www.momsteam.com/node/5744
[8] https://www.momsteam.com/node/867
[9] https://www.momsteam.com/node/2700
[10] https://www.momsteam.com/node/2695
[11] https://www.momsteam.com/node/208
[12] https://www.momsteam.com/node/183
[13] https://www.momsteam.com/node/6581
[14] https://www.momsteam.com/node/3341
[15] https://www.momsteam.com/node/4029
[16] https://www.momsteam.com/node/150
[17] https://www.momsteam.com/health-safety/concussion-education-ineffective-two-new-studies-show
[18] https://www.momsteam.com/sports/honest-self-reporting-concussions-symptoms-critical-for-athletes
[19] https://www.momsteam.com/health-safety/athletes-resistance-to-self-reporting-concussion-continues-despite-increased-education
[20] https://www.momsteam.com/problem-underreporting-concussions-helmet-sensors-solution-to-problem
[21] https://www.momsteam.com/survey-reveals-gaps-in-concussion-knowledge-education-in-high-school-sports
[22] https://www.momsteam.com/health-safety/concussion-education-and-safety-meetings-for-athletes-and-parents-should-be-mandatory
[23] https://www.momsteam.com/health-safety/concussion-education-are-text-messages-wave-future
[24] https://www.momsteam.com/smartphone-applications-provide-concussion-information-for-parents
[25] https://www.momsteam.com/health-safety/concussion-safety-education-personal-momsteam-founder
[26] https://www.momsteam.com/5-7/coaches-play-important-role-in-concussion-safety
[27] https://www.momsteam.com/team-of-experts/coaches-need-to-create-safe-environment-for-reporting-concussions-experts-say