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