Influencing Concussion Reporting Behaviors in High School Athletes

“Be Honest.  Speak Up.”  This phrase is repeated throughout the concussion portion of every ASA™ Program.  Every effort is made to encourage athletes in attendance to be truthful about their concussion symptoms or those of their teammates.  Research has shown that returning to play while still suffering concussion symptoms can lead to more severe and potentially catastrophic head/brain injuries, yet there are still occasions where high school athletes return to play with lingering concussion symptoms.  The question remains, “Why?” 

A recent study in the Journal of Athletic Training attempts to better understand factors that influence concussion reporting in high school athletes.  The researchers hypothesized that improved concussion knowledge and a positive attitude are motivational factors that should increase concussion reporting.  Over a two-year period (2008 – 2010) high school athletes across six sports were asked to complete a survey (167 athletes participated) regarding their knowledge, attitudes, and beliefs about concussions.  Participants were also asked to document previous concussions and concussion-like symptoms and whether or not they reported them to a coach or medical personnel. 

Results of the study show that concussion still continue to be under-reported by student-athletes because of a lack of recognition of concussion signs and symptoms and a negative attitude toward reporting potential concussions.  Specifically, the following was noted:

• Of the 167 athletes who completed the survey 89 reported having at least one concussion or "bell ringer."  Of these 89 athletes only 15 (~17%) reported ALL signs and symptoms to a coach or medical personnel.

• These 89 athletes went on to describe 84 concussions (48% were reported for evaluation) and 584 “ bell ringers” (only 12% were reported for evaluation) demonstrating a significant gap in understanding of what a concussion is.

• In order of most to least cited, the top five reasons for not reporting concussion or concussion-like symptoms included:  1) not believing signs and symptoms were serious enough to report; 2) did not want to be removed from the game; 3) did not want to let down teammates; 4) did not want to let down coaches; and 5) not knowing event was a concussion.

• Athletes still demonstrate a gap in understanding signs and symptoms associated with potential concussions, especially those that are less common or could indicate another condition such as nausea. 

• A majority of athletes still do not believe concussion are serious.  Additionally, they feel the need to down play their symptoms and struggle with feelings of embarrassment when deciding whether or not to report a potential concussion.

For m,e this study bring two major points to light that must continue to be reinforced during concussion education for athletes, parents and coaches.  First, the term “bell ringer” must be removed from the conversation when discussing concussions.  A concussion is a concussion, period.  If an athlete is having concussion-like symptoms s/he should report it and evaluated for a potential concussion.  Coaches, parents and medical professional should not use the term “bell ringer” when talking about concussions or performing clinical evaluations.  It is obvious that the term takes away from the seriousness of a brain injury and students may continue to compete despite their symptoms.  Concussion are serious injuries and this should be emphasized with all parties.

Secondly, the study demonstrates that with increased knowledge around signs and symptoms of concussion students are more likely to realize they may be suffering from a concussion and report it.  Creating an environment where it is expected that symptoms will be reported and taken seriously will minimize the likelihood that student-athletes will downplay their symptoms due to feelings of embarrassment.  Coaches and parents can be most influential in this area and should pay extra attention to the culture they create around toughness and injuries.  It should be very clear that concussions are not injuries that can be “played through.”

Anecdotal personal reports and data collected by A4IA shows that the ASA™ is helping to increase concussion reporting among high school athletes.  Most recently two athletes at Torrey Pines High School reported concussion symptoms to their athletic trainer for evaluation a week after completing the ASA™ curriculum.  Basic analysis of pre-/post- ASA™ Program testing show that students are unaware of many of the signs and symptoms of concussion (similar to those cited in the highlighted study), but also believe you must lose consciousness to suffer a concussion.  Finally, many did not realize that exercise can cause the return of concussion symptoms and that returning to play while still suffering from a concussion can lead to prolonged concussion symptoms or even second impact syndrome (SIS).  ASA emphasizes all signs and symptoms of concussion, the seriousness of these injuries and the potentially catastrophic consequences of participating with concussion.  Following the completion of the ASA™ Program athletes demonstrate a more clear understanding of concussions based on the available post-test data.  They understand that you only lose consciousness in 10% of concussions, can describe second impact syndrome (SIS) and know the importance of a gradual return to play program.  Most of all, they know it is critical to report their symptoms and be evaluated.

It’s a small step, but an impactful one.  As the number of athletes who have completed the ASA™ training grows the gap in concussion knowledge decreases.  Ideally concussion reporting will increase and studies that currently demonstrate concussion under-reporting rates ranging from 40% – 50% will be a thing of the past.  It is important to be sure that concussions are being reported more consistently whether or not there is an athletic trainer available, parents and coaches must continue to educate themselves in concussion recognition and management too.  Be familiar with the available resources and if you have questions ask someone trained in concussion recognition and management.

Submitted by Heather L. Clemons, MS, MBA, ATC

A4IA Looks to Take ASA Program East

The ASA™ Program is familiar to many in San Diego with over 1500 athletes who have completed the program since its inception.  A4IA is looking to expand the ASA™ Program's impact by taking it to other cities around the country.  As a first step A4IA has selected Community Health Network’s Sports Medicine Program in Indianapolis, Indiana and the New Hampshire Musculoskeletal Institute (NHMI) in Manchester, New Hampshire as the locations for upcoming ASA™ programs.  A4IA would like to take time today to introduce you to the athletic trainers behind these two organizations that have been instrumental in bringing ASA™ to their area.  Meet, DeAnne Green, ATC (Community Health Network) and Laura Decoster, ATC (NHMI).  I recently had an opportunity to connect with these athletic trainers and find out why bringing ASA™ to their community was so important to them.

DEANNE GREEN 

DeAnne is a professional athletic trainer who manages Community Health Network’s Sports Medicine Program.  The program is responsible for improving sports medicine health care for athletes in the Indianapolis area.  This includes athletic training coverage for several local high schools and an Indy Car racing team.  There are also a variety of injury clinics/screenings and educational events.  Check out their website for more information!

DeAnne had the pleasure of connecting with Beth through former NATA President, Marjorie Albohm.  Once connected with Beth, the value of the ASA™ Program to Community Health Network’s Sports Medicine mission was immediately obvious.  Community Sports Medicine is already working to educate parents, coaches and athletes to improve their overall well-being and the ASA™ Program’s focus on youth sport safety is one of the key areas for Community’s Sports Medicine. 

DeAnne is most excited about how ASA™ empowers athletes to help each other in a time of need.  In most situations, teammates are often the first one to an injured athlete.  Knowing what to do can be powerful for all athletes on the field.  DeAnne says, “It has been my pleasure to work with Beth, Tommy and A4IA.  Their support of athletic trainers and youth sports safety is awe-inspiring, heart-felt and truly special.  I am proud and honored to share this program in the Indianapolis area.”

LAURA DECOSTER

Laura is a professional athletic trainer who is the Executive Director of the New Hampshire Musculoskeletal Institute (NHMI). NHMI’s largest program, the Safe Sports Network (SSN) focuses on all aspects of youth sport safety for athletes in the Greater Manchester area.  The program provides athletic trainer coverage for seven high schools in the area and runs a drop-in injury clinic in downtown Manchester.  SSN also provides concussion management for youth leagues, including baseline and follow-up cognitive testing.  NHMI also provides extensive opportunities for research and professional development for athletic trainers, physicians and other allied health professionals.  Check out SSN to find out more!

Laura became aware of A4IA when she was working on a video for the SSN and she came across Tommy’s video on YouTube when searching for examples.  Shortly thereafter she met Beth at the Youth Sports Safety Alliance Meeting in Washington, DC (February 2013).  Given NHMI’s focus on youth sport safety through the SSN, ASA™ seemed like a logical addition to what was already being offered.

Laura believes there is value in the ASA™ Program for schools that have an athletic trainer as well as those who do not.  Just like DeAnne, Laura is aware that most often, even when an athletic trainer is on the sidelines it is a teammate that will likely reach an injured athlete first.  Knowing what to do can be the difference between a full recovery and a potential catastrophe.  Empowering athletes to help themselves is the first step in expanding sports medicine coverage for all athletes.  Laura says, “When I heard about ASA, I thought it was brilliant.  I hope that every potentially catastrophic outcome that could be prevented, is prevented.”

The ASA™ Program has already had a tangible impact here in San Diego, with two ASA Ambassadors using their hands-only CPR skills to save a life.  ASA™ has also given over 1500 San Diego athletes the ability to help their teammates in an emergency.  A4IA looks forward to taking their ASA™ and their “What you know may help save someone you know” message on the road.

Submitted by Heather L. Clemons. MS, MBA, ATC

Return to Learning Guidelines Following Concussion

At the end of October the American Academy of Pediatrics (AAP) published a series of guidelines to assist in returning young people to learning following a concussion.  I published a link to the full article on the A4IA Facebook Page shortly thereafter, but I wanted to take the time to introduce the statement to you today.  As we learn more and more about concussions, how to recognize them and how to manage them the idea of cognitive rest along with physical rest has become an increasingly popular concept. 

The concept was even discussed in the guidelines published following the 4^th International Conference on Concussion in Sport held in Zurich last November.  The resulting consensus statement from this conference did not lead to specific guidelines on how to return to learning (RTL).  The AAP has since tackled that project and developed some key concepts that pediatricians, parents and school administrators, staff and teachers should be familiar with.  The intended audience is pediatricians, but I found these guidelines very helpful as an athletic trainer and believe parents and schools will think the same.

You can review the full statement, HERE.

Following my own review of the statement I have the following recommendations for parents who are dealing with a young child or adolescent who has suffered a concussion and returning to learning:

• Remember, everyone’s recovery from a concussion is different.  The rate at which symptoms start to dissipate will vary from person to person and concussion to concussion.  Be flexible and adjust your child’s rest needs based on their symptoms and not “cookbook” recommendations.

• Read the AAP’s entire statement on RTL and be sure your child’s pediatrician is familiar the statement and is willing to work with you and your child’s school to facilitate your child’s recovery and return to school.  Most students will recover within 1-3 weeks and help will only be needed for a short period of time.

• Become familiar with education jargon relative to the various types of academic adjustments that are available so you can communicate clearly with your child’s pediatrician and school (the statement can help with this).

• Become familiar with the resources available at your child’s school from both a health and academic perspective and communicate with appropriate parties as needed while your child is returning to school.  This should be a team effort.  For example, who is the school nurse, school psychologist, athletic trainer, special education contact?

• If your child suffers prolonged post-concussion syndrome it is important to consider further follow up with a neuropsychologist (or other specialist) who is familiar with pediatric concussions.

• Remember, students should be at their academic “baseline” BEFORE returning to sports.

• The statement provides additional concussion resources at the conclusion of the statement and while they were likely intended for pediatricians I believe they may be useful in answering additional questions for parents and others.

Just as returning to sport too soon after a concussion can prolong symptom, it is believed that returning to school too soon can do the same.  It is important to know that research is still being done to continue to clarify RTL guidelines, but based on what we know it appears that the same graded return process that is used for physical exertion is also a useful process when considering cognitive exertion.  In the end, as I always seem to say, be prepared and have a plan.  It’s a team effort to return a child to school and sport following a concussion and the more you know, the more the team will know.

Submitted by Heather L. Clemons, MS, MBA, ATC

ASA Program Key Component of Sportsmanship Summit

Students from Torrey Pines High School and La Costa Canyon High School participated in a sportsmanship summit on October 28^th at San Dieguito Academy.  Athletes Saving Athletes™ was part of this summit in an effort to teach students potential life-saving information and improve cooperation among the students.  The hope was to create student leaders who could reinvigorate a positive competitive spirit among the athletes and their fans.

According to published reports the summit focused on improving leadership skills and sportsmanship between athletes at the schools because of a growing number of incidents at LCC vs. TPHS events.  The most cited event was the boy’s lacrosse championship game last May and thenegative fan behaviors and post-game actions.  While students involved in the rivalry say it is typically healthy competition on the field the number of negative actions of spectators has become increasingly more common.  The rivalry has been ever present given the quality of the athletic programs at LCC and TPHS, but sportsmanship has waned in recent months.

The summit included guest speakers, often alumni of either LCC or TPHS along with the ASA™ program.  The ASA™ program presented its typical “head, heat, heart” program along with teaching Hands-Only CPR™ and how to use an AED.  The program creates student leaders, ASA Ambassadors, who are expected to go back to their teams and share what they learned.  The program also provided hands-on opportunities for students from each school to work together.  The ASA™ program was a key addition to the summit because of its ability to empower students with potential life-saving information, irrespective of team/school affiliation.   

Beth Mallon, Advocates for Injured Athletes founder and CEO was originally contacted by Kari Digiulio, Athletic Director at LLC to help “restore the relationship between the LCC and TP communities.”  Those involved thought it was important to start with the athletes themselves and the ASA™ program seemed the perfect fit, as LCC already had 70 athletes who went through the program last spring.  Additionally, the Athletic Trainers, Sam Villa (LCC) and Christina Scherr (TPHS) taught the curriculum as an example of cooperation between the communities.

Each school nominated and selected 100 athletes to attend the summit. The summit was held at a neutral location (San Dieguito Academy) in an effort to promote a sense of common ground.  Athlete safety is a concern for everyone and knowing how to recognize potentially catastrophic conditions and where to locate AEDs on campus is important for all athletes whether they are teammates or opponents. 

Beth Mallon made the following statement regarding the experience:

“We were honored to participate. We hope the program has a lasting positive impact in the lives of the athletes. We hope the athletes see each other as competitors, but also as the one who might need to step up someday and save a life. Our motto is "What you know may save someone you know".

The group of athletes was AMAZING honestly, I was extremely impressed with the students attending the program. They were polite, respectful, engaged and attentive. It was truly a very special group of young men and women. They should feel very proud they were selected by their coaches and their administration to attend the summit and represent their school.  We are proud as an organization that they represent ASA.”

Submitted by Heather L. Clemons, MS, MBA, ATC