The Effects of Concussion Legislation One Year Later—What Have We Learned: A Descriptive Pilot Survey of Youth Soccer Player Associates

A systematic review of concussion education, knowledge, and attitudes in football

Detecting concussion during football games is difficult due to the complexity of the condition. Medical staff may only enter the field to assess players when the injury is recognised by the referee. With no temporary concussion substitutions available, pitch-side testing often depends on medics recognising, or players self-reporting, symptoms. The aim of this review is to provide a summary of the literature examining the concussion education, knowledge and attitudes of players, coaches, medics, and officials in association football. A literature search based on PRISMA guidelines was conducted using PubMed, SPORTDiscus and Web of Science up to 12 January 2024. Papers were ineligible if the outcome of the survey or questionnaire was concussion incidence or over 50% of participants did not play football. A total of 21 studies were included. Of these studies 14 evaluated concussion education,11 evaluated concussion knowledge and 14 evaluated attitudes towards concussion. Study quality was assessed using the appropriate Joanna Briggs Critical Appraisal Tool. Results show that participants who have previously undergone concussion education have greater concussion knowledge. However, concussion attitudes do not appear to improve with increased concussion knowledge. Players are still likely to continue playing while injured in important games. Coaches, and officials have safer attitudes towards concussion than players. Consistency in participant groups and methods used to test knowledge and attitudes was low. All papers included suffer from medium to high risks of bias, therefore the strength of evidence is weak. Published research examining concussion knowledge, attitudes and education in football is limited.

Mapping the youth soccer: A bibliometrix analysis using R-tool

In recent years, there has been an increase in the scientific production of youth soccer. However, a panoramic map of research on this subject does not exist. The aim of this study was to identify global research trends in youth soccer over time, among the main levels of analysis: sources, authors, documents, and keywords. The bibliometric software Biblioshiny was used to analyze 2606 articles in Web of Science (WoS) published between 2012 and 2021. The main conclusion is that US and UK scholars dominate the research; the topics of research are changing with the real needs, and research on the topic of performance has been of interest to scholars; talent identification and development, performance, injury prevention, and concussion are the studies of interest to scholars in this area. This finding, which offers a global picture of youth soccer research over time, can help future research in this or similar domains.

Concussion Public Policy in Elementary and High Schools in Ontario, Canada: A Cross-Sectional Survey to Examine Implementation Compliance, Barriers, and Facilitators

BACKGROUND

Concussion public policies have been developed to address the burden of concussions. The aim of the present study was to examine implementation compliance, barriers, and facilitators of Canada's first concussion public policy, Ontario's Policy/Program Memorandum 158: School Board Policies on Concussion (PPM158).

METHODS

An electronic survey was sent to 515 randomly selected elementary and high school principals across specific geographic, language, and publicly funded school types in Ontario. Data were analyzed using both qualitative and quantitative methods.

RESULTS

One hundred and thirty-five principals responded to the survey (26%). Concussion education was provided to teachers in 81% of schools, to students in 83%, and coaches in 79%. Additionally, 89% reported having a return-to-learn protocol in place and 90% reported having a return-to-play protocol. Implementation barriers included difficulties in providing concussion education to parents (42%), obtaining notes from physicians, and maintaining the volume of documentation. Eighty-seven percent of respondents believed that PPM158 improves student well-being.

CONCLUSIONS

Identified implementation barriers and facilitators can inform concussion policy practices to improve student well-being. We recommend: (1) an appointed concussion policy lead at each school, (2) electronic documentation, (3) determining the optimal education format to improve parent/guardian education, (4) fostering relationships between schools and health care professionals, and (5) student concussion education in every grade in Ontario schools.

What Do Parents Need to Know About Concussion? Developing Consensus Using the Delphi Method

OBJECTIVE

Many schools and sports leagues provide preseason concussion education to parents/guardians, and in some jurisdictions, it is required for interscholastic sports participation. However, directives about content are absent or vague. The purpose of this study was to obtain expert consensus about what parents/guardians need to know to about concussion.

DESIGN

A modified Delphi process with nationally recognized expert panel members was used to obtain consensus about parent/guardian behaviors relevant to concussion prevention, identification, and management and knowledge domains relevant to performance of those behaviors.

RESULTS

Sixteen parent/guardian behaviors and 24 knowledge domains were identified. However, consensus was not achieved regarding whether it is realistic to expect parents/guardians to perform approximately one-third of the behaviors that experts agreed mattered. This variability may reflect underlying uncertainty about the capacities of some parents/guardians to put knowledge into action or the belief that there are other barriers to action. Furthermore, for most knowledge domains, there was a lack of agreement about whether or not there could be a "correct" answer on the basis of current scientific knowledge.

CONCLUSIONS

These findings raise practical and ethical questions: how can we expect parents/guardians to help prevent, identify, or manage concussion if they cannot have all the information required to engage in these behaviors due to lack of scientific consensus? This issue is not unique to concussion. Best practices for risk communication and shared decision-making can inform how we think about educating parents/guardians about concussion inside and outside of the health care setting.

Original Research: Concussions at School: The Experiences and Knowledge of School Nurses

BACKGROUND

School nurses' knowledge about and confidence in managing concussions are important to ensure continuity of care between a student's school and home environments. This mixed-methods study explored concussion-related knowledge, confidence, and management experiences among urban and rural school nurses in Washington State.

METHODS

Public school nurses, identified via state educational service district websites and recruited by e-mail, completed an online survey assessing their concussion knowledge and confidence levels. Following the survey, a subset of respondents participated in semistructured interviews aimed at exploring their confidence in managing concussions.

RESULTS

Of the 945 school nurses to whom the survey was sent, 315 responded (33% response rate). Most survey respondents held an RN license (89.6%) and were from urban areas (90.8%). Overall, the respondents exhibited accurate concussion knowledge; only one significant difference was noted based on rural-urban status. Correct responses were given for most questions (67.4% to 98.7% correct responses). In interviews with a subset of six school nurses, emergent themes pertained to communication, assessment, and monitoring, and the nurse's role in postconcussion management. Barriers can include a lack of relevant school policies, low concussion awareness among teachers and parents, and limited resources.

CONCLUSIONS

The study findings suggest that school nurses possess high levels of concussion knowledge and confidence in managing concussions. Continuing education remains important to ensure that current research and evidence inform practice regarding ongoing concussion management among school-age children.

Concussion disclosure in middle and high school youth: Who gets the message and are they trained to receive it?

Background

Disclosure of concussion is vital for proper diagnosis and treatment. Youth have many stakeholders to whom they may disclose concussion, including parents, peers, coaches, and school personnel. We examined whom high school and middle school youth report concussion and the level of concussion education of the recipients of the disclosure.

Methods

Data were analyzed from 2362 students, 680 parents, and 150 school personnel who completed an online survey about concussion reporting, education, and training.

Results

Youth were most likely to disclose concussions to parents, particularly mothers, and their peer group. Middle school youth reported to teachers and school nurses at higher rates than high school youth. High school youth were more likely to disclose concussion to coaches and athletic trainers than middle school youth. While mothers were the most likely recipient of youths’ reporting, they were least likely to have received concussion education.

Conclusions

Recipients of youth concussion disclosure differs by school level. Parents are the most common recipients of disclosure. The role of school personnel and coaches changes as youth enter high school. Youth primarily report concussions to parents, yet parents receive the least amount of concussion training. These findings highlight the need for targeted concussion training for stakeholder groups as their role in disclosure may differ by school age.

A qualitative study of barriers and opportunities for concussion communication and management among parents of youth sports athletes

Background:

Concussion, a commonly reported injury among young athletes, can lead to short- and long-term physical, cognitive, emotional, and sleep-related symptoms. Parents are in a unique position to help identify a possible concussion and to support an athlete’s recovery.

Methods:

This qualitative study used a focus group methodology to explore five research questions focused on two main topics: (1) parents’ perception of concussion and (2) parent–athlete communication. Two authors independently reviewed notes from each of the focus groups and then generated a list of emerging themes related to five research questions.

Results:

Parents in this study valued and were interested in discussing concussion with their athletes. However, parents were uncertain about their role in promoting concussion safety and often rely on coaches to communicate with athletes about concussion reporting and recovery. Participants described barriers their athletes may face in concussion reporting and suggested strategies to improve communication about both reporting and recovery.

Conclusion:

Concussion education efforts may benefit from promoting specific actions parents can take to prevent concussion and how to communicate effectively with their child about reporting a possible concussion.

Understanding the Level of Concussion Knowledge in High School Sports in New Jersey

BACKGROUND

Coaches, athletic trainers (ATCs), and parents/guardians (parents) are important contributors to the proper identification and management of concussions in student-athletes. However, there are limited studies on the identification of concussion knowledge gaps that will help inform educational efforts and improve concussion outcomes in these groups.

OBJECTIVE

To identify gaps and factors influencing concussion knowledge for high school athletics.

DESIGN

Survey.

SETTING

Public, private, and recreational leagues in New Jersey.

PARTICIPANTS

41 coaches, 34 ATCs, and 65 parents of high school student-athletes.

METHODS

A 17-item online survey examining concussion knowledge was distributed to coaches, ATCs, and parents. Analyses included ANOVA for between-group comparisons of continuous variables and Pearson's correlations for categorical data.

MAIN OUTCOME MEASUREMENTS

Demographics, concussion knowledge, application of knowledge, access to educational materials, and confidence in the ability to identify concussions.

RESULTS

Significant between-group differences were found for overall knowledge (F[2137] = 11.0, P < .001), factual knowledge (F[2137] = 8.7, P < .001), and application of knowledge (F[2137] = 3.5, P = .03), with parents scoring lower. Coaches, ATCs, and parents had gaps in factual knowledge of baseline testing scores and identification regarding symptom severity. More coaches (73.2%) and ATCs (97.1%) felt confident in concussion knowledge compared with parents (31.3%; P < .001). All groups thought mandatory education, new law, and guidelines were positive in promoting better care of student-athletes.

CONCLUSIONS

Knowledge gaps were identified in all groups. Educational programs for these groups should consider including targeted techniques, including vignettes, to illustrate application of concussion knowledge.

LEVEL OF EVIDENCE

III.

Parental knowledge of concussion: Evaluation of the CDC's "Heads up to parents" educational initiative

BACKGROUND

Potential negative outcomes associated with sport-related concussion drive the need for resources to educate parents about prevention, recognition, and management of concussion in the youth athlete. Parents play a critical role in the recognition and management of concussion for their child.

PURPOSE

This study aims to (a) investigate current knowledge of concussion among parents whose children age 5-18 years play a club sport and (b) identify effects of an online video versus online print educational intervention on concussion knowledge change and learning.

METHODS

140 parents whose children played a club sport answered questions regarding their knowledge of sport-related concussion pre- and post-random assignment to an educational intervention: CDC Concussion Awareness video or CDC Concussion Fact Sheet for Parents.

RESULTS

Participating parents demonstrated a moderate level of pre-intervention knowledge, but critical gaps in knowledge were identified. Knowledge of concussion improved slightly following intervention regardless of intervention type.

CONCLUSIONS

This study confirms the presence of gaps in knowledge of concussion in parents whose children play club sports. Without the protection of concussion legislation, those athletes who participate in club sports are at particular risk due to lack of concussion knowledge and education. This study confirms that education can have a positive impact on parental knowledge of concussion. Practical applications: Pre-knowledge of concussion is the greatest predictor of post-knowledge of concussion, therefore pre-assessment of target audience knowledge followed by a custom educational intervention taking into account principles of adult learning, would be the most beneficial to increasing concussion knowledge.

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

Sport-Related Concussion: Knowledge and Reporting Behaviors Among Collegiate Club-Sport Athletes

CONTEXT: 

Previous literature on sport-related concussion (SRC) knowledge and reporting behaviors has been limited to high school and National Collegiate Athletic Association collegiate athletes; however, knowledge regarding collegiate club-sport athletes is limited.

OBJECTIVE: 

To determine the level of SRC knowledge and reporting behaviors among collegiate club-sport athletes and to investigate differences between athletes in traditional and nontraditional sports.

DESIGN: 

Cross-sectional study.

SETTING: 

Survey.

PATIENTS OR OTHER PARTICIPANTS: 

A total of 410 athletes (247 males, 163 females) involved in traditional (n = 244) or nontraditional (n = 165) collegiate club sports.

MAIN OUTCOME MEASURE(S): 

The survey consisted of demographics, recognition of SRC signs and symptoms, general SRC knowledge, and reasons why athletes would not report SRCs. The independent variable was sport type. Sport-related concussion signs and symptoms and general knowledge were assessed by the frequency of correct answers to SRC signs and symptoms and general knowledge questions. Sport-related concussion-reporting behavior frequencies were evaluated by asking participants to indicate reasons why they did not or would not report an SRC.

RESULTS: 

The SRC signs and symptoms knowledge score was 23.01 ± 3.19 and general SRC knowledge score was 36.49 ± 4.16 (maximal score = 43). No differences were present for SRC signs and symptoms knowledge ( F_1,408 = 1.99, P = .16) or general SRC knowledge ( F_1,408 = 3.28, P = .07) between athletes in traditional and nontraditional collegiate club sports. The most common reason for not reporting an SRC was not recognizing it as a serious injury (n = 165, 40.3%). Chi-square tests demonstrated significant relationships between sport type and 5 reasons for not reporting an SRC.

CONCLUSIONS: 

The participants displayed moderate to high levels of knowledge of SRCs but indicated they had failed to or would fail to report SRCs for a variety of reasons. The lack of sports medicine coverage and disconnect between knowledge and injury recognition may make collegiate club-sport athletes more likely to participate while concussed.

Pilot single-centre cross-sectional study to determine emergency physicians' knowledge and management of sports concussion: an experience from Singapore

INTRODUCTION

Sports concussion remains challenging to manage despite changes to policy and practice since the 2012 International Consensus Conference on Concussion in Sport. Emergency physicians (EPs) are usually the first line of medical care for athletes in amateur and youth collision sports. This single-centre cross-sectional study aimed to establish EPs' understanding and management of concussion in Singapore.

METHODS

An anonymised, 17-item online questionnaire was sent to EPs requesting for information on their clinical experience, training, exposure to concussion cases in the emergency department (ED) and assessed knowledge of the condition.

RESULTS

Out of 65 EPs, 52 (80%) responded, 25 (48.1%) of whom were medical officers. Over 90% had not received formal training in concussion management, and 73.1% regularly assessed concussion. 40 (76.9%) EPs recognised that loss of consciousness was not essential for diagnosis and only 24 (46.2%) knew the most common symptom. 26 (50.0%) incorrectly reported that they would perform brain imaging. Among those who indicated onward referral, 29 (55.8%) would refer concussed patients to neurosurgery. There were no significant differences between clinical grade or training in concussion and positive responses for definition, imaging modality or most common symptom of concussion.

CONCLUSION

Concussion is a common presentation to EDs in Singapore. However, understanding of the condition, its clinical diagnosis, investigation and onward management is limited. Although EPs reported training in concussion, it is likely to be insufficient. Commencing relevant education programmes for undergraduate and postgraduate medical students may enable progressive acquisition of knowledge and thereby improve patient management in the future.

Calling Injury Timeouts for the Medical Evaluation of Concussion: Determinants of Collegiate Football Officials' Behavior

CONTEXT

  Sports officials can play an important role in concussion safety by calling injury timeouts so that athletic trainers can evaluate athletes with possible concussions. Understanding the determinants of whether officials call an injury timeout when they suspect a concussion has important implications for the design of interventions to better support officials in this role.

OBJECTIVE

  To assess the knowledge of US collegiate football officials about concussion symptoms and to determine the associations between knowledge, perceived injunctive norms, and self-efficacy in calling injury timeouts for suspected concussions.

DESIGN

  Cross-sectional study.

SETTING

  Electronic survey.

PATIENTS OR OTHER PARTICIPANTS

  Of the 3074 US collegiate football officials contacted, 1324 (43% response rate) participated.

MAIN OUTCOME MEASURE(S)

  Concussion knowledge, injunctive norms (belief about what others would want them to do), and behavioral self-efficacy (confidence in their ability to call injury timeouts for suspected concussions in athletes during challenging game-day conditions).

RESULTS

  Officials reported calling approximately 1 injury timeout for a suspected concussion every 4 games during the 2015 season. Structural equation modeling indicated that officials with more concussion-symptom knowledge had greater self-efficacy. Independent of an official's symptom knowledge, injunctive norms that were more supportive of calling an injury timeout were associated with greater self-efficacy.

CONCLUSIONS

  Concussion education for officials is important because when officials are aware of concussion symptoms, they are more confident in calling injury timeouts. Beyond increasing symptom knowledge, fostering sports environments that encourage concussion safety can support officials in calling injury timeouts. Athletic trainers can help by educating stakeholders, including officials, about the importance of concussion safety. When officials believe that other stakeholders support concussion safety, they are more likely to call injury timeouts if they suspect a concussion has occurred.

A Scoping Review to Address the Culture of Concussion in Youth and High School Sports

BACKGROUND

In 2013, the National Academy of Sciences emphasized the need to develop, implement, and evaluate effective large-scale educational strategies to improve the culture of concussion in youth and high school sports. In support of this recommendation, in this article we summarize research on factors that contribute to the culture of concussion.

METHODS

We conducted the literature search using 7 electronic databases. We used a scoping review method to identify studies that addressed knowledge, attitudes, behaviors, use of educational resources, and interventions related to concussion among young athletes, coaches, and parents.

RESULTS

Of the 33 articles identified, most focused on concussion education (N = 15), followed by knowledge (N = 13), behaviors (N = 13), and attitudes (N = 5). Three studies addressed multiple study populations.

CONCLUSIONS

The rapid spread of concussion education and awareness efforts has outpaced research on effective strategies to improve knowledge, attitudes, and behaviors that contribute to the culture of concussion. Further research is critical to inform the development and implementation of large-scale educational efforts. This research should incorporate rigorous study designs; be inclusive of diverse ages, socioeconomic status, and racial/ethnic groups; and examine opportunities to improve behavioral outcomes around concussion prevention, reporting, and management.

Factors Influencing the Underreporting of Concussion in Sports: A Qualitative Study of Minor Hockey Participants

OBJECTIVE

The present study is to identify factors contributing to underreporting of concussion in adolescent athletes.

DESIGN

Qualitative interviews.

SETTING

Participants were interviewed in an office environment.

PARTICIPANTS

Interviews were conducted with 31 minor hockey players, 10 parents, 6 coaches, 4 trainers, 2 managers, and one game official. Players were 13 to 15 year old. With selective sampling, an inductive approach of analyzing the interviews was undertaken and themes were identified and analyzed.

ASSESSMENT OF RISK FACTORS

Underreporting is a complex phenomenon. A number of risk factors related to hockey culture, players, reference others, and rules of play were assessed.

MAIN OUTCOME MEASURES

Reasons not reporting concussion is accepted in minor hockey.

RESULTS

Aspects of hockey culture such as an overemphasis on winning games and upheld misperceptions about the risks associated with concussion were identified as relevant to the underreporting of concussions. Various factors relevant to the underreporting of concussions include player's motivation to win, group membership dynamics such as a player's role as the team's "enforcer," coaches' own motivation to win to further their own opportunities in the sport, and parents' personal financial interest or alternative agenda in terms of time commitments and their child's future career prospects.

CONCLUSIONS

Our findings indicate that underreporting of concussion among those players interviewed appears to be prevalent and associated with misconceptions about injury risk, and a culture that both reinforces and encourages underreporting with tacit or overt complicity of parents and coaches. Our findings support the need to alter the culture of violence and tough play in hockey by education, rule changes, economic measures, and changes in governance of the sport. Interviewing more stakeholders and policy makers would shed light on such potential interventions.

A Multifactorial Approach to Sport-Related Concussion Prevention and Education: Application of the Socioecological Framework

OBJECTIVE

To offer an overview of sport-related concussion (SRC) prevention and education strategies in the context of the socioecological framework (SEF). Athletic trainers (ATs) will understand the many factors that interact to influence SRC prevention and the implications of these interactions for effective SRC education.

BACKGROUND

Concussion is a complex injury that is challenging to identify and manage, particularly when athletes fail to disclose symptoms to their health care providers. Education is 1 strategy for increasing disclosure. However, limited information addresses how ATs can integrate the many factors that may influence the effectiveness of SRC education into their specific settings. Public health models provide an example through the SEF, which highlights the interplay among various levels of society and sport that can facilitate SRC prevention strategies, including education.

DESCRIPTION

For ATs to develop appropriate SRC prevention strategies, a framework for application is needed. A growing body of information concerning SRC prevention indicates that knowledge alone is insufficient to change concussion-related behaviors. The SEF allows this information to be considered at levels such as policy and societal, community, interpersonal (relationships), and intrapersonal (athlete). The use of such a framework will facilitate more comprehensive SRC prevention efforts that can be applied in all athletic training practice settings. Clinical Applications: Athletic trainers can use this information as they plan SRC prevention strategies in their specific settings. This approach will aid in addressing the layers of complexity that exist when developing a concussion-management policy and plan.

Legislation for Youth Sport Concussion in Canada: Review, Conceptual Framework, and Recommendations

In this article, we conduct a review of introduced and enacted youth concussion legislation in Canada and present a conceptual framework and recommendations for future youth sport concussion laws. We conducted online searches of federal, provincial, and territorial legislatures to identify youth concussion bills that were introduced or successfully enacted into law. Internet searches were carried out from July 26 and 27, 2016. Online searches identified six youth concussion bills that were introduced in provincial legislatures, including two in Ontario and Nova Scotia and one each in British Columbia and Quebec. One of these bills (Ontario Bill 149, Rowan's Law Advisory Committee Act, 2016) was enacted into provincial law; it is not actual concussion legislation, but rather a framework for possible enactment of legislation. Two bills have been introduced in federal parliament but neither bill has been enacted into law. At present, there is no provincial or federal concussion legislation that directly legislates concussion education, prevention, management, or policy in youth sports in Canada. The conceptual framework and recommendations presented here should be used to guide the design and implementation of future youth sport concussion laws in Canada.

The Massachusetts School Sports Concussions Law: A Qualitative Study of Local Implementation Experiences

BACKGROUND

Reducing the incidence and negative consequences of concussion among youth athletes is a public health priority. In 2010, Massachusetts passed legislation aimed at addressing the issue of concussions in school athletics. We sought to understand local-level implementation decisions of the Massachusetts concussion law.

METHODS

A qualitative multiple-case study approach was utilized. Semi-structured interviews with school-employed actors associated with the law's implementation were used for analysis. Interview data were subjected to a conventional content analysis.

RESULTS

A total of 19 participants from 5 schools were interviewed. Schools were purposefully selected from communities varying in socioeconomic status and population. Participants included 5 athletic directors, 5 coaches, 4 athletic trainers, 4 school nurses, and 1 health and wellness coordinator. Eight themes emerged regarding specific ways schools have implemented the law. Six themes emerged regarding factors influencing implementation.

CONCLUSIONS

All cases employ neurocognitive testing as a means to assess concussions, place decision-making authority in athletic trainers' hands, and use a 30-minute online video to disseminate concussion education. Employing athletic trainers could pose challenges to school districts with limited financial capacity, as financial assistance from the state is not provided under the law. The validity of neurocognitive testing and the effectiveness of online concussion training need further study. Cooperation from student athletes, their parents, and physicians is necessary for full implementation of the law.

High School Football Players' Knowledge and Attitudes About Concussions

OBJECTIVES

To assess high school (HS) football players' knowledge of concussions and to determine whether increased knowledge is correlated with better attitudes toward reporting concussion symptoms and abstaining from play.

DESIGN

Two survey tools were used to assess athletes' knowledge and attitudes about concussions. Surveys collected information about demographics, knowledge about concussions, and attitudes about playing sports after a concussion. All athletes present completed one of the 2 surveys. A knowledge and attitude score for each survey was calculated. Frequencies and mean values were used to characterize the population; regression analysis, analysis of variance, and t tests were used to look for associations.

SETTING

A football camp for HS athletes in the Cincinnati area.

PARTICIPANTS

Male HS football players from competitive football programs in the Cincinnati area.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Scores on knowledge and attitude sections; responses to individual questions.

RESULTS

One hundred twenty (100%) athletes were enrolled although not every athlete responded to every question. Thirty (25%) reported history of a concussion; 82 (70%) reported receiving prior concussion education. More than 75% correctly recognized all concussion symptoms that were asked, except "feeling in a fog" [n = 63 (53%)]. One hundred nine (92%) recognized a risk of serious injury if they return to play too quickly. Sixty-four (54%) athletes would report symptoms of a concussion to their coach; 62 (53%) would continue to play with a headache from an injury. There was no association between knowledge score and attitude score (P = 0.08).

CONCLUSIONS

Despite having knowledge about the symptoms and danger of concussions, many HS football athletes in our sample did not have a positive attitude toward reporting symptoms or abstaining from play after a concussion.

CLINICAL RELEVANCE

Physicians should be aware that young athletes may not report concussion symptoms.

Sports-Related Concussion

Sports-related concussions (SRC) are common in all ages and occur in all sports. The diagnosis based on clinical suspicion after more serious injury is ruled out. Symptoms of concussion are due to a temporary and reversible neurometabolic cascade resulting in blood flow changes, neuronal excitotoxicity, ionic shifts, and mitochondrial changes. Symptoms are nonspecific, and commonly include headache, cognitive complaints, photophobia, and phonophobia. Loss of consciousness is rare in SRC and has limited influence on recovery and prognosis. Imaging has a limited role in the management of concussion and should be used to evaluate for more serious intracranial pathology. Treatment is based on symptoms and an understanding of the typical, rapid (7-10 days) recovery. No athlete should return to play until their symptoms have resolved and they have completed a supervised, step-wise return to play protocol. The article covers the most recent literature on the diagnosis and management of SRC, including evidence-based recommendations and expert-based consensus opinion. The article will also discuss issues regarding medical retirement, legislation, and future concepts in concussion diagnosis and management.

Sport-Related Concussion Reporting and State Legislative Effects

OBJECTIVE

To investigate concussion rates and reporting frequencies in high school and collegiate athletes in 2013, compare results to those obtained from 1999 to 2002, and examine to what extent the 2012 Wisconsin state concussion law affected reporting in 2013.

DESIGN

Retrospective 2013 survey compared with prior survey.

SETTING

High schools and colleges in the Milwaukee, Wisconsin, area.

PARTICIPANTS

Athletes (N = 784) from multiple sports were surveyed in 2013. Football players (N = 1532) from 1999 to 2002 completed the same measure.

MAIN OUTCOME MEASURES

Both surveys assessed concussion history, concussion incidence during the current season, whether incident concussions were reported, who concussions were reported to, and reasons for not reporting. The 2013 survey also assessed awareness of the Wisconsin state law and its effect on reporting.

RESULTS

Rates of concussion in the surveyed season were comparable to previous findings from 1999 to 2002 (16.6% vs 15.3%, P = 0.558). Notably, athletes were significantly more likely to report their concussions in 2013 (70.6% vs 47.3% previously, P = 0.011). Among high school athletes surveyed, 59.5% were aware of the Wisconsin state law, with 55.1% stating it would make them more likely to report a concussion.

CONCLUSIONS

Rates of concussion for 1 sport season have not changed significantly over the past 14 years. The percentage of concussions that are reported to someone has increased significantly. Awareness of the Wisconsin state law does not fully account for the increase in concussion reporting.

CLINICAL RELEVANCE

Given the finite amount of knowledge regarding the influence of concussion-related cultural and legal changes, these findings will help to inform clinicians of the current concussion milieu from the perspective of athletes. It will inform practitioners involved in concussion management to what extent athletes are aware of and report concussions.

Assessment of parental knowledge and attitudes toward pediatric sports-related concussions

Background:

Parents of young athletes play a major role in the identification and management of sports-related concussions. However, they are often unaware of the consequences of concussions and recommended management techniques.

Hypothesis:

This study quantitatively assessed parental understanding of concussions to identify specific populations in need of additional education. We predicted that parents with increased education and prior sports- and concussion-related experience would have more knowledge and safer attitudes toward concussions.

Study Design:

Cross-sectional survey.

Level of Evidence:

Level 5.

Methods:

Participants were parents of children brought to a pediatric hospital and 4 satellite clinics for evaluation of orthopaedic injuries. Participants completed a validated questionnaire that assessed knowledge of concussion symptoms, attitudes regarding diagnosis and return-to-play guidelines, and previous sports- and concussion-related experience.

Results:

Over 8 months, 214 parents completed surveys. Participants scored an average of 18.4 (possible, 0-25) on the Concussion Knowledge Index and 63.1 (possible, 15-75) on the Concussion Attitude Index. Attitudes were safest among white women, and knowledge increased with income and education levels. Previous sports experience did not affect knowledge or attitudes, but parents who reported experiencing an undiagnosed concussion had significantly better concussion knowledge than those who did not.

Conclusion:

Parents with low income and education levels may benefit from additional concussion-related education.

Clinical Relevance:

There exist many opportunities for improvement in parental knowledge and attitudes about pediatric sports-related concussions. Ongoing efforts to understand parental knowledge of concussions will inform the development of a strategic and tailored approach to the prevention and management of pediatric concussions.

Return to rugby after brain concussion: a prospective study in 35 high level rugby players

Background:

Although guidelines based on expert opinions have been developed for the immediate management and return to play of athletes after a concussion, data are lacking on this issue.

Objectives:

Evaluate a standardized management of brain concussion among rugby players to prevent the recurrence.

Patients and Methods:

A prospective study was performed from September 2009 to June 2012. All rugby players who had a concussion when playing rugby were included. Patients were managed by a specialized hospital team with a specific protocol developed in collaboration with the medical staff of the rugby clubs included in the study. The series included 35 rugby players, with 23 professionals and 12 high-level players, 30 men and 5 women, mean age 23.1 ± 5.5 years old. The median number of previous concussions was 2 (0-30) episodes. According to the Cantu concussion severity classification, 3 athletes were grade 1, 12 were grade 2 and 20 were grade 3. None of the injured athletes was lost to follow-up. The primary endpoint was the occurrence of a new concussion within 3 months after the first in patients who returned to rugby.

Results:

Thirty-three patients returned to rugby after a mean 22.1 ± 10 days. The recurrence rate within 3 months was 2/33 (6.1%). The median delay before returning to rugby was 21 (7-45) days. Factors associated with a delayed return to play were young age, initial loss of consciousness, severity Cantu grade 3 and post-concussive syndrome of more than 5 days. Analysis of two failures showed that the initial injury was grade 3 and that both were professional athletes and had a history of concussion.

Conclusions:

This prospective study validated the study protocol for the management of concussion in rugby players.

Evaluation of the Zachery Lystedt Law among female youth soccer players

BACKGROUND

Despite recent increased awareness about sports concussions, few studies have evaluated the effect of concussion laws on concussion outcomes among young athletes. The purpose of our study was to evaluate the effect of the Washington State Zachery Lystedt Concussion Law on playing with concussion symptoms and being evaluated by a health care provider.

METHODS

We performed a prospective cohort study of 351 elite female soccer players, aged 12 to 15 years, from 33 randomly selected youth soccer teams in the Puget Sound region of Washington State from 2008 to 2012. The Washington State Zachery Lystedt Concussion Law went into effect on July 1, 2009. Among concussed players (N = 59), we assessed the risk of playing with symptoms, the evaluation by a health care professional, and receiving a concussion diagnosis before and after the law was passed using logistic regression to estimate odds ratios and 95% CIs.

RESULTS

The majority of concussed players (59.3%) continued to play with symptoms, and we found no statistically significant difference in the proportion of players who played with symptoms before and after the law was passed. Only 44.1% of concussed players were evaluated by a health care provider, with no difference before and after the law was passed. Among those evaluated by a health care professional, players were 2.1-fold (95% CI, 1.0-10.1) more likely to receive a concussion diagnosis after the law was passed.

CONCLUSION

The majority of concussed female youth soccer players report playing with symptoms. Legislation mandating concussion education and evaluation prior to returning to play was not associated with an increase in concussion evaluations by health care providers.

Return to play management after concussion in football: recommendations for team physicians

A concussion is a rare but potentially serious injury of football players. Thus, an immediate and valid diagnosis, estimate of severity and therapeutic management is required. To summarise the published information on management of concussion with respect to a safe return to play (RTP), a literature search was conducted. Current guidelines on concussion in sports and significant studies on concussion in football were analysed. After concussion, management and RTP decision should remain in the area of clinical judgement on an individualised basis according to the current international guidelines. If a concussion is suspected, the player should not be allowed to RTP the same day. The RTP programme should follow a gradual step-wise procedure. A concussed player should not RTP unless he/she is asymptomatic and the neurological and neuropsychological examinations are normal. Untimely RTP bears an increased risk of sustaining another more severe brain injury and repetitive brain injury of long-term sequelae. In football, the management of concussion should primarily follow the recommendations proposed by the Concussion in Sports Group. Information and education of players and their medical and coaching team help to protect the players' health. Future studies on concussion should include validated and detailed information on RTP protocols.

Washington State's Lystedt law in concussion documentation in Seattle public high schools

CONTEXT

The Lystedt law requires high school athletes who have sustained a concussion to be removed from practice and play and not to be allowed to return until cleared by a medical professional.

OBJECTIVE

To determine the effect of the Lystedt law on injury and concussion documentation in the Seattle public high schools.

DESIGN

Cross-sectional study.

SETTING

Seattle public high schools.

PATIENTS OR OTHER PARTICIPANTS

The numbers of students, aged 13 to 19 years in the 2008-2009, 2009-2010, and 2010-2011 school years, were 4348, 4925, and 4806, respectively.

MAIN OUTCOME MEASURE(S)

All injuries documented in SportsWare by athletic trainers in Seattle public high schools. We evaluated all injuries, including concussions recorded during the 2008-2009 school year, before the Lystedt law, and during the 2 school years after the law took effect (2009-2010 and 2010-2011). Incidence rates before and after the law were estimated and compared.

RESULTS

The concussion rate was -1.09% in 2008-2009, 2.26% in 2009-2010, and 2.26% in 2010-2011. A comparison of relative risks showed that the incidence rates of concussions were different before and 1 year after the Lystedt law (relative risk = 2.10; 95% confidence interval [CI] = 1.50, 2.93) and 2 years after the law (relative risk = 2.10; 95% CI = 1.49, 2.93). Overall, the mean number of days out of play after 2008-2009 was almost 7 days greater after the law took effect (difference = 6.9 days; 95% CI = 0.70, 13.1). For females, the mean number of days out of play after 2008-2009 was more than 17 days in 2009-2010 (difference = 17.2 days; 95% CI = 4.81, 29.5) and was more than 6 days in 2010-2011 (difference = 6.3 days; 95% CI = 1.62, 11.0).

CONCLUSIONS

The number of documented concussions more than doubled after the institution of the Lystedt law, which may be attributed to heightened awareness and closer monitoring.

Implementation of concussion legislation and extent of concussion education for athletes, parents, and coaches in Washington State

BACKGROUND

Most states in the United States have passed laws regarding concussions, but little is known regarding the implementation of these laws. Hypothesis/

PURPOSE

The purpose of this study was to survey high school coaches 3 years after the passage of a concussion law to evaluate the variation in concussion education and knowledge in the context of this law as well as measure the effects of sport (football vs soccer) and urban versus rural locations. The hypothesis was that concussion education and knowledge would be more extensive in football compared with soccer and in urban locations compared with rural locations.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

A mixed-methods (paper and online) survey was conducted in 2012 to 2013 on a random sample of public high school football, girls' soccer, and boys' soccer coaches in Washington State, stratified by urban and rural locality. The survey covered the extent of concussion education for coaches, athletes, and parents as well as coaches' concussion knowledge and experience.

RESULTS

Of 496 coaches contacted, 270 responded (54.4%). Nearly all coaches answered concussion knowledge questions correctly, and nearly all coaches received education via ≥2 modalities (written, video, slide presentation, test, and in person). Athlete education was less extensive, with 34.7% exposed to ≥2 modalities and 29.5% only signing a concussion information form. Parent education was even more limited, with 16.2% exposed to ≥2 modalities and 57.9% only signing a concussion information form. Significantly more football than soccer coaches gave their athletes an in-person talk about concussions (59.1% vs. 39.4%, respectively; P = .002) and provided concussion education to athletes via ≥2 modalities (44.1% vs. 29.7%, respectively; P = .02). Concussion education for coaches and parents was similar between sports, and concussion education for all parties was similar in urban and rural localities.

CONCLUSION

Three years after the passage of a concussion law in Washington State, high school football and soccer coaches are receiving substantial concussion education and have good concussion knowledge. Concussion education for athletes and parents is more limited. Football players receive more extensive concussion education than do soccer players.

CLINICAL RELEVANCE

Clinicians should be aware that athletes and parents may not be receiving significant concussion education.

Concussions and heading in soccer: a review of the evidence of incidence, mechanisms, biomarkers and neurocognitive outcomes

BACKGROUND

Soccer is currently the most popular and fastest-growing sport worldwide. Similar to many sports, soccer carries an inherent risk of injury, including concussion. Soccer is also unique in the use of 'heading'. The present paper provides a comprehensive review of the research examining the incidence, mechanisms, biomarkers of injury and neurocognitive outcomes of concussions and heading in soccer.

METHODS

Seven databases were searched for articles from 1806 to 24 May 2013. Articles obtained by the electronic search were reviewed for relevance, with 229 selected for review. Ultimately, 49 articles met criteria for inclusion in the present review.

RESULTS

Female soccer players have a higher incidence of concussions than males. The most frequent injury mechanism is player-to-player contact for both genders. Few studies examined the effects of concussion in soccer players; however, neurocognitive outcomes were similar to those reported in the larger sport concussion literature, while the effect of heading is less clear.

CONCLUSION

Despite variation in research designs and study characteristics, the outcomes of concussions in soccer align with the greater concussion literature. This review makes recommendations for future research to increase standardization of research for improved understanding of concussions in soccer as well as the effects of heading.

Comparative analysis of state-level concussion legislation and review of current practices in concussion

Object

Forty-two states and the District of Columbia have passed legislation based on the Lystedt law of Washington state, enacted in 2009 to protect young athletes who have sustained a concussion. The aim of this study was to note the several similarities and differences among the various laws.

Methods

Concussion legislation was compared for 50 states and the District of Columbia. Evaluation parameters of this study included stipulations of concussion education, criteria for removal from play, requirements for evaluation and return to play after concussion, and individuals required to assess young athletes. Other parameters that were not consistent across states were also noted.

Results

Forty-three states and the District of Columbia have passed concussion legislation, and an additional 4 states have pending legislation. All states with existing legislation support concussion education for coaches; however, only 48% require coaches to undergo formal education. Athletes must be educated on concussion in 86% of states and parents in 88.7%. Suspicion of concussion is a criterion for removal from play in 75% of states; signs and symptoms of concussion are criteria for removal from play in 16% of states. The individuals allowed to evaluate and clear an athlete for return to play differ greatly among states.

Conclusions

Injury prevention legislation holds historical precedent, and given the increasing attention to long-term sequelae of repeated head trauma and concussion, concussion legislation has been rapidly passed in 43 states and the District of Columbia. Although the exact stipulations of these laws vary among states, the overall theme is to increase recognition of concussion in young athletes and ensure that they are appropriately cleared for return to play after concussion.