Effectiveness of the SLICE program for youth concussion education

Traumatic brain injuries in paediatric patients: individual vs. team sports-related hospitalizations

Paediatric sport participation continues to increase in the United States, with a corresponding increase in sports-related concussions or traumatic brain injuries (TBIs). It is important to recognize which sports are at elevated risk and identify risk factors for hospital admission and length of stay (LOS). Paediatric patients (ages 5-18) from 2008 to 2014 were identified from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). Eight hundred and ninety-four patients included those who were hospitalized with a TBI resulting from participation in an individual (451 patients) or team (443 patients) sport. We evaluated the differences in LOS and total charges between individual and team sports and found that compared to team sports, TBI patients in individual sports had significantly longer hospital stays compared to team sports (1.75 days versus 1.34 days, p < 0.001) and costlier ($27,333 versus $19,069, p < 0.001) hospital stays. This may be due to reduced awareness and reduced compliance with return-to-play protocols in individual sports. Safety education information at a young age, increased awareness of TBIs, and additional medical support for individual sports as well as team sports may help mitigate these findings.

Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design

OBJECTIVES

To understand Canadian university athletic programme concussion management needs, and to describe development and content of a tailored online concussion education tool for Canadian university/college athletes.

DESIGN

An integrated knowledge translation multiphased, multimethods approach was used. Phases included a needs assessment survey with university representatives and athletes, content selection, mapping behavioural goals to evidenced-based behaviour change techniques, script/storyboard development, engagement interviews with university athletes and tool development using user-centred design techniques.

SETTING

Canadian U SPORTS universities (n=56).

PARTICIPANTS

Overall, 64 university representatives (eg, administrators, clinicians) and 27 varsity athletes (52% male, 48% female) completed the needs assessment survey. Five athletes participated in engagement interviews.

OUTCOME MEASURES

Surveys assessed previous athlete concussion education, recommendations for concussion topics and tool design, concussion management challenges and interest in implementing a new course.

RESULTS

Institutions used a median (Med) of two (range 1-5) approaches when educating athletes about concussion. Common approaches were classroom-style education (50%), online training (41%) and informational handouts (39%). University representatives rated most important topics as: (1) what is a concussion, (2) how to recognise a concussion and (3) how to report a concussion (Medall=4.8/5). Athletes felt symptom recognition (96%) and effects on the brain (85%) were most important. The majority of athletes preferred learning via computer (81%) and preferred to learn alone (48%) versus group learning (7%). The final resource was designed to influence four behaviours: (1) report symptoms, (2) seek care, (3) encourage teammates to report symptoms and (4) support teammates through concussion recovery. Examples of behaviour change techniques included: knowledge/skills, problem-solving scenarios, verbal persuasion and social comparison. Athletes are guided through different interactions (eg, videos, flip cards, scenarios, testimonials) to maximise engagement (material review takes ~30 min).

CONCLUSIONS

The Concussion Awareness Training Tool for athletes is the first Canadian education tool designed to address the needs of Canadian university/college athletes.

A Behavior Analytic Interpretation of Concussion Reporting in Athletes: How the Field of Behavior Analysis Can Help Make Athletes Safer

Concussion resulting from athletic activities is a frequent occurrence in youth, collegiate, and professional sports. The first step in concussion treatment is usually the self-reporting of concussion symptoms by athletes. Unfortunately, over the past decade, concussion nondisclosure has remained a prominent concern in concussion identification. This review begins with a summary of the prominent theories being used to explain the deficit in concussion reporting (ie, lack of concussion knowledge, negative attitudes toward reporting, and socioecological models). Unfortunately, current literature indicates that these theories may not often lead to effective treatments for reporting behavior. We then present an alternative model of concussion reporting, one based on the theories of behavior analysis. The deficit in concussion reporting by athletes may be explained in a comprehensive yet parsimonious way through the behavior analytic principles of differential reinforcement and punishment. We also discuss directions for potential intervention strategies based on behavioral theory.

Concussion Education in the School Setting: A Scoping Review

BACKGROUND

Concussions are a prevalent injury among youth, and concussion education has the potential to promote positive concussion-related behaviors. Recent recommendations and legislation have increased concussion education provided in schools; however, little is known about the education context, delivery method, development, and evaluation. A scoping review was conducted to identify peer-reviewed literature on concussion education delivered in the school setting.

METHODS

Six databases were searched (MEDLINE, CINAHL, EMBASE, PsycINFO, SPORTDiscus, and ERIC) to identify published articles from 2002 to July 16, 2020 that delivered concussion education in the school setting. Included studies described the concussion education and were written in English.

RESULTS

A total of 11,373 articles were identified and screened, with 27 studies meeting eligibility criteria and therefore, included. The studies delivered education to various stakeholders including students (n = 12; 44.4%), coaches (n = 5; 18.5%), educators (n = 3; 11.1%), parents (n = 1; 3.7%), and a mixed audience (n = 6; 22.2%). The education format varied and six studies (22.2%) developed the education based on a theory, model, or framework.

CONCLUSIONS

This study found substantial variability in the context, delivery method, development, and evaluation of education delivered in schools and further evaluation of this education is needed to ensure it is best-suited for school-based stakeholders.

Participating in Two Video Concussion Education Programs Sequentially Improves Concussion-Reporting Intention

Undiagnosed concussions increase the risk of additional concussion and persistent symptoms from concussion. Because there are no reliable objective markers of concussion, self-reporting of subjective and non-visible symptoms are critical to ensuring proper concussion management. For this reason, educational interventions target concussion reporting, but the majority of studies have examined the efficacy of single educational interventions or compared interventions to one another. This randomized crossover study sought to identify whether there was benefit to administering multiple concussion education programs in tandem, back to back. The study randomized 313 male high school football players to first receive CrashCourse concussion education (CC) or Centers for Disease Control and Prevention video concussion education (CDC) followed by crossover with the other education. Athlete concussion-reporting intention, attitudes, subjective norms, perceived behavioral control, and enjoyment of education were assessed at baseline and after each intervention. There were statistically significant improvements across all measures, both after single intervention and crossover (all p < 0.001). Secondary analyses examining differences between education found that athletes reported higher enjoyment of concussion education immediately after participating in CC, as compared to CDC (p < 0.001). These findings demonstrate an additive benefit to implementing CC and CDC education in tandem, without decrement in enjoyment of concussion education after experiencing dual educations; in fact, enjoyment of concussion education improved after receiving education programs back to back. These educational programs appear to complement one another, and the results support the use of multi-modal concussion education to differentially target and maximize concussion reporting.

Do Mountain Bikers Know When They Have Had a Concussion and, Do They Know to Stop Riding?

OBJECTIVE

To establish the prevalence of concussions in mountain bikers and to determine factors that increase their risk of concussion. Secondary objectives include determination of whether mountain bikers have undiagnosed concussions, continue to ride after experiencing concussion symptoms, and if they knowingly ride with a broken helmet.

DESIGN

Retrospective survey.

SETTING

Seven-day mountain bike stage race.

PARTICIPANTS

Two hundred nineteen mountain bikers.

MAIN OUTCOME MEASURES

Number of rider concussions diagnosed, number of riders experiencing concussion symptoms without diagnosed concussions, number of riders who continue to ride after experiencing a concussion symptom, and number of riders who rode with a broken helmet.

INDEPENDENT VARIABLES

The independent variables studied included age, gender, nationality, number of times riding in past year, style of riding (cross-country, downhill, or freeride), years mountain biking, years mountain bike racing, whether they are a sponsored cyclist, and whether they also ride a road bike.

RESULTS

Fifteen of 219 mountain bikers (6.9%) had a diagnosed concussion after being hit in the head while mountain biking within the past year, with older riders having a decreased risk [odds ratio (OR), 0.91; P = 0.04], and sponsored riders having a 5-fold increased risk compared with nonsponsored riders (OR, 4.20; P = 0.05). Twenty-eight riders (12.8%) experienced a concussion symptom without being diagnosed with a concussion and 67.5% of the riders who experienced a concussion symptom continued to ride afterward. Overall, 29.2% of riders reported riding with a broken helmet.

CONCLUSIONS

The yearly prevalence of diagnosed concussions in mountain bikers is 6.9%. More than one-third of mountain bikers do not recognize when they have had a concussion and continue riding after experiencing concussion symptoms or with a broken helmet. These behaviors increase their risk of worsening concussion symptoms and acquiring a second injury.

Cognitions That Support Concussion Reporting in Collegiate Athletes: An Analysis of a Worksheet Activity

BACKGROUND

Sports related concussions continue to be a public health concern and improving reporting behavior a focus of educational programs. While educational programs have addressed changes in knowledge of concussion symptoms, it has been challenging to design educational programs which have lasting effects on reporting behavior.

AIMS

The current analysis describes an intervention in which thoughts about reporting behavior are actively written down in a worksheet exercise to "pre-arm" athletes with cognitions designed to enhance reporting behavior prior to the injury event.

METHOD

A total of 503 male and female college athletes participating in collision (football, field hockey, ice hockey, lacrosse, and soccer) and contact sports (baseball, basketball, and softball) from 7 colleges/universities competing across all three NCAA divisions provided data collected during a randomized trial of a peer concussion education program.

RESULTS

Qualitative analysis revealed 10 themes that would improve reporting including short-term benefits, faster recover, safe and healthy return to play, reporting helps the team, reporting protects the brain, risk aversion, long-term benefits, coach will be supportive, teammates will be supportive and understanding, and academic performance will be affected.

DISCUSSION

Athletes had awareness of key risks involved in concussions and understood both short- and long-term consequences.

CONCLUSION

These findings have important implications for understanding how to change athletes' thoughts about reporting concussions.

Psychometric properties of concussion knowledge and cognitive mediators of reporting measures

Context: Concussion education and prevention programs require reliable and valid instruments to evaluate the theory, mechanisms, and outcome of these interventions Objective: To assess the psychometric properties of measures evaluating concussion education and prevention programsDesign: Descriptive epidemiological Setting: 10 NCAA-member universities Patients or Other Participants: 841 student-athletes in an RCT control group testing an ecological, peer-led concussion education program Main Outcome Measures: Instruments adapted for assessing concussion knowledge and Theory of Planned Behavior/Theory of Reasoned Action (TPB/TRA) cognitive mediators of reporting behavior (attitudes, subjective norms, perceived control, and intentions to report concussion). Participants completed measures at baseline, after one hour, and after one month Results: Internal consistency and test-retest reliability were moderate for both the concussion knowledge and cognitive mediator measures. TPB/TRA was supported subscale intercorrelation and item factor analysis in the cognitive mediator scale. Factor analysis of the concussion knowledge measure revealed subscales for physical/cognitive, psychological/affective, and non-symptoms. The intermediate TPB/TRA mediators of attitudes, norms, and perceived control predicted greater intention-to-report, which predicted increased likelihood of reporting concussion one month later.Conclusions: Measures of concussion knowledge and cognitive mediators of reporting adapted from the literature show adequate psychometric properties and support TPB/TRA application for concussion reporting behaviors.

Collegiate athletes' perceptions of the culture of concussion reporting

The current study was designed to understand the culture of concussion among college student-athletes. Participants: Eight men's lacrosse and seven women's soccer players. Methods: A focus group was conducted to understand thoughts, barriers, team culture, and what was needed to feel safe reporting symptoms. Thematic analysis was conducted to identify key themes. Results: Themes included concerns about being taken out, pushing through, wanting to play, severity influencing reporting, changes about concussion reporting, uncertainty about symptoms, concussion have changed the game, reporting a teammate, wanting someone else to make the call, desire to raise awareness, deception, wanting professors to have more understanding, circumstances influencing reporting, helmets specific for concussion, malingering, and the return to play protocol being too long. Conclusion: Factors ranging from intrinsic to more distal cultural and environmental factors appear to influence reporting concussions. Student-athletes identified factors unique to the college athlete environment.

In it to win it: Competitiveness, concussion knowledge and nondisclosure in athletes

OBJECTIVES

Despite having a general understanding of concussions, many athletes choose not to report symptoms of a sports-related concussion (SRC) which leads to a larger burden on our healthcare system due to longer recoveries, more Emergency Department visits, and future medical appointments. Thus, there is a need to identify factors, such as competitiveness, that may help to better explain the nondisclosure of concussion symptoms. The current study aimed to investigate the role of athletes' concussion knowledge and competitiveness on concussion nondisclosure.

METHODS

Participants included 161 Canadian athletes (ages 14-32; 71% male) participating in collision sports (American football, rugby, hockey), soccer or rowing. Concussion knowledge, reporting and competitiveness were measured using the Rosenbaum Concussion Attitude and Knowledge Survey and Sports Orientation Questionnaire (SOQ). Two logistic regression models were performed to explain both history and future intention of playing despite experiencing concussion symptoms.

RESULTS

Age, sex, and concussion knowledge were not significant for the regression models. The SOQ scores (measuring competitiveness) were significant for both regression models, such that higher competitiveness was associated with increased likelihood for past nondisclosure (b =.03, p =.03, OR = 1.03 (97.5% CI: 1.003,1.06)) and future nondisclosure intention (b =.05, p =.00, OR = 1.05 (97.5% CI: 1.03,1.08)). Regarding concussion knowledge, soccer players had significantly higher knowledge than those in collision sports and rugby, F(2, 158) = 140.5, p =.00; female athletes had significantly higher knowledge than males, t(66) = -4.26, p =.00; age was negatively associated with concussion knowledge (r = -0.35, p < .01).

CONCLUSION

The results suggest that healthcare providers should be aware that athletes tend to have adequate concussion knowledge, but this knowledge does not explain past nondisclosure or future nondisclosure intention. Based on these findings, healthcare providers should focus on being able to identify highly competitive athletes who are most at risk of nondisclosure instead of exclusively aiming to increase concussion knowledge in athletes.

Baseline Concussion Testing Increases Agreement With Favorable Concussion Safety Decisions in Hypothetical Scenarios

BACKGROUND

Dangers of sports-related concussion are well documented, and those participating in sports involving significant contact are at an even higher risk relative to the general population. Despite extensive concussion education, athletes still make decisions that would be considered unsafe, such as underreporting and continuing to play despite experiencing symptoms. Although baseline testing is an increasingly common practice at all levels of sport, little is known about its ability to improve player safety perceptions.

AIMS

The current study examines whether taking part in a standardized baseline concussion assessment changes athletes' knowledge, attitudes, or perceptions of concussion safety decisions.

METHOD

A total of 229 club and National Collegiate Athletic Association athletes completed a modified Rosenbaum Concussion Knowledge and Attitudes Survey-Student Version (RoCKAS-ST), which was used to evaluate knowledge, attitudes, and perceptions of concussion safety decisions in hypothetical scenarios. Athletes were randomly assigned to either complete baseline concussion testing prior to the RoCKAS-ST or complete baseline testing after the RoCKAS-ST.

RESULTS

Athletes randomly assigned to complete baseline testing before the RoCKAS-ST demonstrated greater agreement with favorable concussion safety decisions in hypothetical scenarios relative to athletes completing baseline testing after the RoCKAS-ST. The two conditions did not differ with respect to concussion knowledge or attitudes.

DISCUSSION

Baseline testing appears to have an added benefit of resulting in more favorable perceptions toward making safe decisions following suspected concussions.

CONCLUSION

Baseline testing may provide an effective means of improving a broader constellation of concussion safety behavior, particularly in club athletes, who are typically underserved in terms of concussion-related resources and care.

Youth Soccer Parents' Attitudes and Perceptions About Concussions

PURPOSE

Parents are important figures in properly managing youth sport concussions. Although media attention has predominantly centered on concussions in contact/collision sports, evidence suggests that the concussion rate in soccer is comparable to those found in contact/collision sports. Given the high rate of concussions in youth soccer, this study aimed to examine parents of youth soccer athletes' attitudes and perceptions about concussions and associated factors.

METHODS

A cross-sectional study was conducted by surveying parents of youth soccer athletes from the five largest organized youth soccer programs across the U.S. The researchers developed a questionnaire after an extensive literature review and by modifying previously used instruments.

RESULTS

Overall, 419 parents completed the survey. The vast majority (85%) agreed that a concussion is a serious injury, but only 27.9% believed that their child could suffer a concussion during the next season. Parents were most concerned about permanent brain damage when their child suffers a concussion. The vast majority (4.37 ± .89) perceived concussion reporting as an important injury prevention strategy. Greater appreciation and perceived risk about concussions was found particularly among parents who received concussion education and those who had witnessed or heard about a concussive incidence(s).

CONCLUSIONS

Findings suggest that youth soccer parents have high appreciation and perceived risk about concussions. However, the need for more targeted education was noted, as improvements to better manage and reduce concussions can be made. Future research should continue examining youth sport parents' belief and understanding about concussions as well as factors affecting them.

Athlete concussion history recall is underestimated: a validation study of self-reported concussion history among current professional rugby union players

Objective: To assess the concurrent validity and test re-test reliability of the Michigan Traumatic Brain Injury Identification Method (MTBIIM). The psychometric properties of this concussion index were investigated by comparing the agreement between player self-reported diagnosed concussions and medical record diagnosed concussions among professional rugby union players.Study Design: Cross-sectional study i) validation and ii) test re-test reliability.Methods: The MTBIIM was administered via a structured interview to obtain the number and nature of player self-reported concussion histories from players, while contracted to the host club. Self-reported concussion history information was compared to medically recorded data captured between 2008 and 2017. A mixed-effects logistic regression model explored predictors of player self-report accuracy.Results: Data from 62 players (25.39[4.36] years) included 99 unique rugby related concussions. Medically documented concussions (n = 92) per player (1.48 [1.96]) were 30% more than the mean number of self-reported diagnosed (n = 63) concussions per player (1.02 [1.21] events). Overall, self-reported diagnosed concussions and medical record diagnosed concussion histories had a 'fair' level of agreement (k=0.274; SE [0.076]), p=.001). Self-reported lifetime concussion history was signicantly negatively correlated with recall of concussions.Conclusions: Initial concurrent validity of the MTBIIM was found to be fair with the average athlete under-reporting the number of clinically diagnosed concussions.

Development of a Peer Education Program to Improve Concussion Knowledge and Reporting in Collegiate Athletes

CONTEXT

A novel peer concussion-education program (PCEP) was developed to enhance concussion knowledge and reporting among collegiate student-athletes.

OBJECTIVE

To describe the PCEP and its development and implementation.

DESIGN

Program development consisting of a literature review, focus group, and pilot implementation.

SETTING

Athletics department at a college participating at the National Collegiate Athletic Association Division II-sanctioned competition level.

PATIENTS OR OTHER PARTICIPANTS

Fifteen student-athletes from the women's soccer and men's lacrosse teams participated in the focus group. Four peer concussion educators (PCEs) were debriefed after the pilot implementation of the PCEP with the women's soccer and men's lacrosse teams.

DATA COLLECTION AND ANALYSIS

Focus-group data were analyzed qualitatively. The PCEs were debriefed, and responses were organized into recommendation types.

RESULTS

The literature review contributed information that supported the development of the PCEP's conceptual model. Focus-group results provided information used to train the PCEs and refine the PCEP's education modules. The pilot implementation and PCE debriefing supplied information used to further revise the education modules, PCE training, and PCEP implementation procedure.

CONCLUSIONS

The PCEP was developed based on the Theory of Reasoned Action and Planned Behavior and uses a peer-mediated, cognitive-behavioral, and interdisciplinary model to enhance concussion knowledge of and reporting by collegiate student-athletes. After a focus-group discussion and pilot implementation, we revised the PCEP and its education modules and developed an online manual to facilitate broad dissemination.

The youth concussion awareness network (You-CAN) - a school-based peer-led intervention to improve concussion reporting and social support: the protocol for a cluster randomized trial

Background

Concussion prevalence is increasing in the pediatric population, and is a matter of public health concern. Concussion symptoms can be physical, cognitive, emotional and behavioural, and last longer in high school aged youth than adults. Concussions are underreported in youth due to their lack of knowledge, social environment, perceived outcomes of reporting, norms, and self-efficacy. The Youth Concussion Awareness Network (You-CAN) is a school-based peer-led program designed to increase high school students’ intent to report a concussion, and provide social support to a peer. This study aims to investigate whether participation in You-CAN, a program grounded in service learning principles, impacts concussion knowledge, attitudes, intent to report a suspected concussion to an adult, and intent to provide social support to a peer. Secondary aims include assessing the implementation fidelity and acceptability of the intervention.

Methods

This longitudinal study will use a cluster randomized trial design. Three high schools from six randomly selected Canadian school boards will participate and be randomized to three study arms: (1) You-CAN led by school staff; (2) You-CAN led by school staff and research team; and (3) untreated comparison group. Intervention arms 1 and 2 will deliver the You-CAN program and create a Concussion Council at their school. The Concussion Council will deliver a concussion awareness campaign and participate in an online showcase with other participating schools. In addition, arm 2 will have monthly video-calls with the research team. A survey based on the Theory of Planned Behaviour will be administered school-wide with all arms (1, 2, 3) at two time points (beginning {T₀} and end {T₁} of the school year). Exit interviews will be completed with the Concussion Councils and participating school staff.

Discussion

This study will provide evidence of the effectiveness of a school-based peer-led concussion program on increasing concussion knowledge, attitudes, subjective norms, perceived behavioural control, intent to report a concussion to an adult, and intent to provide social support to a peer amongst Canadian high school students. It will also provide important information about the implementation and acceptability of the You-CAN program for high school students and staff.

Trial registration

This trial is registered with the ISRCTN registry (ISRCTN64944275, 14/01/2020, retrospectively registered).

Barriers to the Implementation of State Concussion Laws Within High Schools

PURPOSE

All 50 U.S. states and the District of Columbia enacted concussion laws between 2009 and 2014 to mitigate the consequences of concussion among children and adolescents. In response, many high schools started to implement their respective state law that includes three main tenets: (1) concussion education, (2) removal from play, and (3) return-to-play. We aimed to identify barriers to the implementation of these tenets at the school level.

METHODS

We conducted 64 semistructured telephone interviews with high school athletic trainers from 26 states and the District of Columbia whose school participated in High School Reporting Information Online during the 2014-2015 and 2015-2016 academic years. Data were analyzed using thematic analysis.

RESULTS

All 64 high schools employed at least one athletic trainer, and most schools were public schools (90.6%). Implementation barriers to the concussion education tenet were (1) lack of quality education, (2) lack of buy-in to educational requirements, and (3) lack of time for and attendance at educational meetings. Implementation barriers to the removal from play tenet included (1) athletes underreporting concussion symptoms, (2) lack of communication, (3) resistance from parents and coaches, and (4) sport culture and "old school" mentality. Finally, (1) cost of and access to medical care, (2) resistance from stakeholders, and (3) lack of understanding of concussion were identified as implementation barriers to the return-to-play tenet.

CONCLUSIONS

Identification of implementation barriers is key to the successful execution and application of state concussion laws at the school level. Future research should identify strategies to reduce these barriers.

Concussion Education in Children and Youth: A Scoping Review

INTRODUCTION

Sports-related concussions in children and youth are a significant health concern. There is increasing literature pertaining to levels of knowledge about concussion and the effects of educational interventions, but the literature has not yet been synthesized for the subpopulation of children and youth. Therefore, the purpose of this review was to identify and summarize the current state of the literature on concussion knowledge, and the effect of concussion education on the knowledge, attitudes, and behaviors of children and youth who engage in sports.

METHODS

A scoping review was conducted, guided by Joanna Briggs Institute methodology. Two databases, MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature), and reference lists were searched to identify relevant studies that focused on children and youth less than 19 years of age who engage in sports. We also searched Google Scholar for gray literature.

RESULTS

Of the 21 articles that met inclusion criteria, 15 focused on levels of concussion knowledge, and 6 examined the effects of educational interventions. Children and youths' level of knowledge and exposure to prior concussion education varied, although more of the studies found a lack of concussion knowledge. Educational interventions of various types have been associated with short-term increases in knowledge and intention to report, but few of the studies found sustained effects.

CONCLUSIONS

Findings highlight the need for improved concussion education for children and youth engaged in sports. Findings also indicate a need for further research using more rigorous methods, and studies that examine subgroup differences in knowledge and factors that may moderate the effects of educational interventions.

The changing nature of concussion in rugby union: Looking back to look forward

Introduction

Concussion is regularly observed in rugby union and has generated a growing public health concern, yet remains one of the least understood injuries facing the sports medicine community. Evidence suggests that multiple concussions may increase susceptibility to long-term neurological complications that present decades after the initial injury for reasons that remain unclear. We aimed to determine the incidence rate and risk factors for concussion amongst community-level rugby union-15s players active during the 1980s given that it may help to better understand the risks and mechanisms of injury.

Methods

Injury data were collected from clubs by the coach at the time of injury in players using a 15-item questionnaire (1982–1984).

Results

Seventy games were recorded throughout 1982–1983 and 1983–1984 rugby union seasons. Forty-two documented concussions accounted for ∼6% of injuries corresponding to an incidence rate of 0.64 per 1000 playing hours, more than a third lower than the ‘modern-day’ equivalent. Tackling (relative risk 1.60, p < 0.05), collisions (relative risk 0.95, p < 0.05) and gum shield use (relative risk 1.69, p < 0.05) were independently associated with concussion whereas no associations were observed for ground condition, quarter of play or players playing out of position ( p > 0.05).

Conclusion

Despite limitations due to the retrospective focus and reliance on questionnaire data notwithstanding raised awareness of concussion, the incidence rate of concussion during the 1980s appears to be appreciably lower compared to the present-day game. This is the likely outcome of improvements in the clinical understanding of concussion, data collection tools, reporting methods and clinical management of concussive injuries, including changes to both player and game. However, the findings of this study help better understand the risks and mechanisms of injury once encountered by rugby union players active during the 1980s, of which some of those risks are still apparent.

Predictors of Collegiate Student-Athletes' Concussion-Related Knowledge and Behaviors

OBJECTIVE

This study aimed to explore student-athletes' concussion-related knowledge and attitudes toward reporting symptoms, demographic predictors of knowledge and attitudes, and determine whether responses to the survey changed following an online educational intervention.

METHODS

A total of 108 Division I student-athletes enrolled at a large southern university completed a survey evaluating knowledge regarding concussion-related terminology, symptoms and recovery trajectories, as well as attitudes toward reporting symptoms following a possible concussion. Student-athletes completed the questionnaire both 24-48 h before and one week after reviewing the educational presentation.

RESULTS

At baseline, participants correctly identified 72% of concussion symptoms included in the questionnaire, as well as correctly identified 75% of items related to the typical recovery trajectory post-concussion. A total of 54% of baseline attitudes toward reporting symptoms matched clinical best practices. Multiple analysis of variance (MANOVA) revealed that male sex and non-Caucasian race were associated with worse baseline knowledge of concussion symptoms. Concussion knowledge was not associated with attitudes toward reporting symptoms. Paired samples t-tests indicated that knowledge of concussion-related terminology improved modestly following the educational presentation.

CONCLUSIONS

Some subsets of collegiate student-athletes show relatively lower knowledge about symptoms of concussion than others. As a result, these groups may benefit from increased educational efforts to ensure they recognize when a concussion may have occurred. Additionally, as knowledge and attitudes were unrelated and the intervention had a modest effect on knowledge but not attitudes, future work should explore interventions that are designed to directly alter attitudes.

Socioecological influences on concussion reporting by NCAA Division 1 athletes in high-risk sports

Concussion among athletes is an issue of growing concern, with efforts underway to improve detection, diagnosis, and treatment. Success depends on communication by athletes, as brain-related symptoms are often not outwardly visible. Education programs to increase reporting behavior have not been successful to date. In accordance with the socioecological approach to health, we argue that multiple levels of influence on student athletes must be addressed, and report a multi-dimensional, mixed-methods research project conducted to identify possible points of intervention into changing the culture of concussion-injury reporting among collegiate athletes. Using quantitative, qualitative and interpretive methods, we examine the individual-level vested interests athletes have in reporting or not reporting concussion symptoms, and how these interests interact with community-level team culture and interpersonal relationships, and social-level cultural narratives to influence concussion-reporting behavior. Our findings confirm the viability of this approach, identifying immediacy, separation of responsibility and pain-enduring story systems as particularly salient elements. We conclude that competing performance versus safety value structures, reflected in cultural narratives and team culture, create mixed-messages for athletes, which are resolved in favor of performance because athletes perceive concussion injuries to be of low immediacy.

Evaluation of a theory-based concussion education program for secondary school student-athletes in Ireland

Concussion education is an important aspect of concussion prevention. The purpose of this study was to investigate the effect of a novel, theory of planned behavior (TPB)-driven concussion education program on secondary school athletes' concussion-reporting relevant cognitions immediately post-intervention and at 3 months follow-up. Data were collected from 428 secondary school athletes during the 2016-2017 academic year: 229 were assigned to an intervention group of which 59 (25.76%) completed assessments at all timepoints; 199 were assigned to a control group of which 153 (76.88%) completed assessments at all timepoints. Using repeated measures ANOVAs, we examined differences in athletes' concussion-reporting cognitions, by group and gender. The program had a significant positive effect on athletes' knowledge (P < 0.01), perceived behavioral control over concussion recognition and reporting (P < 0.01), and reporting intention (P < 0.01). These results were maintained at 3 months follow-up, with the exception of perceived behavioral control. The program did not have a significant effect on athletes' attitudes toward concussion reporting and subjective reporting norms. Results suggest that the TPB may be a useful framework to inform the development of more effective educational programs. There is a need for multi-layered interventions that aim to create sporting environments that encourage positive concussion care seeking behaviors.

Gender differences in concussion-related knowledge, attitudes and reporting-behaviours among high school student-athletes

BACKGROUND/AIM

Sport-related concussion is associated with various short- and long-term health consequences, especially among adolescent athletes. Yet, many concussions go unreported and/or unrecognised. The purpose of this study was to assess high school athletes' concussion-related knowledge, attitudes, intentions and reporting behaviours, and to explore whether gender differences are evident.

METHODS

A total of 435 high school athletes (52.2% female; mean age, 14.55 ± 1.67 years) participated in the survey. Questions assessed athletes' knowledge, attitudes, reporting intention and reporting behaviours, in respect to sports-related concussion. Comparisons between male and female athletes were explored using Mann-Whitney tests and chi-squared (χ²) tests as appropriate.

RESULTS

We found that 60% of the participants stated that they have played in practice or during a game (this season) with concussion symptoms. Males expressed more negative outcomes of concussion reporting and lower concussion reporting intention, compared to females. We found no significant gender differences in concussion-reporting behaviours.

CONCLUSION

Our findings suggest that knowledge, favourable attitudes towards reporting and reporting intention alone are not enough to create an environment that encourages the disclosure of concussion symptoms. Health promotion communication campaigns, coupled with concussion education and awareness programmes, should be utilised to further highlight the importance of timely concussion management, and to create a culture in which the reporting of concussion is considered normative.

A pilot educational intervention for headache and concussion: The headache and arts program

OBJECTIVE

Using a science, technology, engineering, arts, and mathematics (STEAM) curriculum, we developed, piloted, and tested the Headache and Arts Program. This program seeks to increase knowledge and awareness of migraine and concussion among high school students through a visual arts-based curriculum.

METHODS

We developed a 2-week Headache and Arts Program with lesson plans and art assignments for high school visual arts classes and an age-appropriate assessment to assess students' knowledge of migraine and concussion. We assessed students' knowledge through (1) the creation of artwork that depicted the experience of a migraine or concussion, (2) the conception and implementation of methods to transfer knowledge gained through the program, and (3) preassessment and postassessment results. The assessment was distributed to all students prior to the Headache and Arts Program. In a smaller sample, we distributed the assessment 3 months after the program to assess longitudinal effects. Descriptive analyses and p values were calculated using SPSS V.24 and Microsoft Excel.

RESULTS

Forty-eight students participated in the research program. Students created artwork that integrated STEAM knowledge learned through the program and applied creative methods to teach others about migraine and concussion. At baseline, students' total scores averaged 67.6% correct. Total scores for the longitudinal preassessment, immediate postassessment, and delayed 3-month postassessment averaged 69.4%, 72.8%, and 80.0% correct, respectively.

CONCLUSION

The use of a visual arts-based curriculum may be effective for migraine and concussion education among high school students.

Exploring concussion awareness in hockey with a First Nations community in Canada

OBJECTIVE

The purpose of this pilot study was twofold: (1) to begin to understand concussion in youth hockey in a First Nations community in Canada and (2) to determine the impact of a novel concussion education workshop.

DESIGN

A one-group quasiexperimental time series study was undertaken.

SAMPLE

A total of 41 participants consented, with 71% (n = 29) completing data collection at all three study time points.

MEASUREMENT AND INTERVENTIONS

Two nurses one from the First Nations community and one from the tertiary care center collaborated to develop and deliver the intervention on concussion specifically general, hockey and symptom knowledge. The primary outcome was Total Knowledge Score (TKS), whereby correct responses to a self-reported questionnaire were summed and then converted to a percentage.

RESULTS

The TKS were similar across study time points; preworkshop 71.7%, postworkshop 71.8%, and 6-month follow-up 72%.

CONCLUSIONS

Nurses worked collaboratively with cultural experts from a First Nations community to integrate Indigenous ways of knowing into concussion awareness and safety for First Nations youth playing hockey.

What do coaches want to know about sports-related concussion? A needs assessment study

PURPOSE

This study aims to identify the concussion-related training and education needs of Gaelic Athletic Association (GAA) coaches in Ireland, as well as the preferred method of concussion education delivery.

METHODS

We used a self-report questionnaire to collect data from a convenience sample of 108 GAA coaches in Ireland. Data were captured on (1) informational needs and desires, (2) preferred methods of delivery, and (3) concussion practices and procedures. Questionnaires were completed electronically from June 3rd-September 29th, 2015.

RESULTS

Coaches indicated that they were most interested in receiving information about the (1) signs and symptoms of concussion, (2) assessment of concussion, and (3) return-to-play guidelines. Over two-thirds of participants indicated that in-person training would be the most effective mode of delivery of concussion education for this population. Additionally, only 10% coaches reported that before the start of the season they talked to their athletes about concussion management and safety, and this was more common among coaches who reported being formally educated about concussion.

CONCLUSION

Our findings reveal a disconnect between the concussion education needs and the education that is currently provided to GAA coaches, in terms of content and delivery modality. Our results suggest a need for a multifaceted approach to concussion education, tailored to the needs and learning preferences of the target population.

Why Professional Football Players Chose Not to Reveal Their Concussion Symptoms During a Practice or Game

OBJECTIVE

To determine why professional football players in Canada decided not to seek medical attention during a game or practice when they believed they had suffered a concussion.

DESIGN

Retrospective survey.

SETTING

Preseason Canadian Football League training camps.

PARTICIPANTS

Four hundred fifty-four male professional football players.

MAIN OUTCOME MEASURES

Reasons athletes did not seek medical attention for a presumed concussion during the previous season, how often this occurred and how important these reasons were in the decision process.

RESULTS

One hundred six of the 454 respondents (23.4%) believed they had suffered a concussion during their previous football season and 87 of the 106 (82.1%) did not seek medical attention for a concussion at least once during that season. The response "Did not feel the concussion was serious/severe and felt you could still continue to play with little danger to yourself" was the most commonly listed reason (49/106) for not seeking medical attention for a presumed concussion. Many players answered that they did not seek medical attention because they did not want to be removed from a game (42/106) and/or they did not want to risk missing future games (41/106) by being diagnosed with a concussion.

CONCLUSIONS

Some professional football players who believed they had suffered a concussion chose not to seek medical attention at the time of injury. Players seemed educated about the concussion evaluation process and possible treatment guidelines, but this knowledge did not necessarily translate into safe and appropriate behavior at the time of injury.

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.

Examining the psychometric properties of a sport-related concussion survey: a Rasch measurement approach

BACKGROUND

Awareness of sport-related concussion (SRC) is an essential step in increasing the number of athletes or parents who report on SRC. This awareness is important, as there is no established data on medical care at youth-level sports and may be limited to individuals with only first aid training. In this circumstance, aside from the coach, it is the players and their parents who need to be aware of possible signs and symptoms. The aim of this study was to examine the psychometric properties of a parent and player concussion survey intended for use before and after an education campaign regarding SRC.

METHODS

1441 questionnaires were received from parents and 284 questionnaires from players. The responses to the sixteen-item section of the questionnaire's 'recognition of signs and symptoms' were submitted to psychometric analysis using the dichotomous and polytomous Rasch model via the Rasch Unidimensional Measurement Model software RUMM2030. The Rasch model of Modern Test Theory can be considered a refinement of, or advance on, traditional analyses of an instrument's psychometric properties.

RESULTS

The main finding is that these sixteen items measure two factors: items that are symptoms of concussion and items that are not symptoms of concussion. Parents and athletes were able to identify most or all of the symptoms, but were not as good at distinguishing symptoms that are not symptoms of concussion. Analyzing these responses revealed differential item functioning for parents and athletes on non-symptom items. When the DIF was resolved a significant difference was found between parents and athletes.

CONCLUSIONS

The main finding is that the items measure two 'dimensions' in concussion symptom recognition. The first dimension consists of those items that are symptoms of concussion and the second dimension of those items that are not symptoms of concussion. Parents and players were able to identify most or all of the symptoms of concussion, so one would not expect to pick up any positive change on these items after an education campaign. Parents and players were not as good at distinguishing symptoms that are not symptoms of concussion. It is on these items that one may possibly expect improvement to manifest, so to evaluate the effectiveness of an education campaign it would pay to look for improvement in distinguishing symptoms that are not symptoms of concussion.

Sex Differences in High School Athletes' Knowledge of Sport-Related Concussion Symptoms and Reporting Behaviors

CONTEXT

  Recent researchers have reported that athletes' knowledge of sport-related concussion (SRC) has increased but that athletes still lack knowledge of all the signs and symptoms of SRC. Understanding the signs and symptoms of SRC and the dangers of playing while symptomatic are critical to reporting behaviors in high school athletes.

OBJECTIVE

  To examine sex differences in knowledge of SRC symptoms and reasons for not reporting a suspected SRC to an authoritative figure in high school athletes.

DESIGN

  Cross-sectional study.

SETTING

  Survey.

PATIENTS OR OTHER PARTICIPANTS

  A total of 288 athletes across 7 sports (198 males [68.8%] and 90 females [31.2%]).

MAIN OUTCOME MEASURE(S)

  A validated knowledge-of-SRC survey consisted of demographic questions, a list of 21 signs and symptoms of SRC, and reasons why athletes would not report their SRC. The independent variable was sex. Athlete knowledge of SRC symptoms was assessed by having participants identify the signs and symptoms of SRC from a list of 21 symptoms. Knowledge scores were calculated by summing the number of correct answers; scores ranged from 0 to 21, with a score closer to 21 representing greater knowledge. Reporting-behavior questions asked athletes to choose reasons why they decided not to report any possible SRC signs and symptoms to an authoritative figure.

RESULTS

  A sex difference in total SRC symptom knowledge was found (F₂₈₆ = 4.97, P = .03, d = 0.26). Female high school athletes had more total SRC symptom knowledge (mean ± standard deviation = 15.06 ± 2.63; 95% confidence interval = 14.54, 15.57) than males (14.36 ± 2.76; 95% confidence interval = 13.97, 14.74). Chi-square tests identified significant relationships between sex and 8 different reasons for not reporting an SRC.

CONCLUSIONS

  High school males and females had similar SRC symptom knowledge; however, female athletes were more likely to report their concussive symptoms to an authoritative figure.

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.

Mandated High School Concussion Education and Collegiate Athletes' Understanding of Concussion

CONTEXT

  Concussions in student-athletes are a serious problem. Most states have enacted legislation mandating concussion education for student-athletes, under the assumption that education leads to better self-reporting of concussions and improved knowledge of symptoms.

OBJECTIVES

  (1) To determine the effect of state-based concussion legislation on the proportion of student-athletes receiving concussion education and to assess the moderation of this effect by gender and sport and (2) to assess the effect of concussion education on student-athletes' knowledge of concussion symptoms and likelihood of seeking treatment after a concussion.

DESIGN

  Cross-sectional study.

SETTING

  Private university.

PATIENTS OR OTHER PARTICIPANTS

  A total of 249 National Association of Intercollegiate Athletics collegiate athletes attending St Xavier University; 160 were surveyed prelegislation and 89 were surveyed postlegislation.

MAIN OUTCOME MEASURE(S)

  Participants completed an anonymous survey that assessed previous involvement in concussion-education programs, degree of self-reporting after a concussion, and ability to enumerate symptoms.

RESULTS

  The number of athletes who reported having received education increased after the implementation of concussion legislation; however, almost 25% still reported not having received education. Athletes who played football were more likely to report having received education than those who played volleyball. The student-athletes' ability to name a diversity of concussion symptoms or to report seeking medical attention after a concussion did not improve in the postlegislation period relative to the prelegislation period.

CONCLUSIONS

  Legislation has been passed in all 50 states to address concussions in student-athletes; however, improvements are still needed. Concussion education must be delivered in a uniform, effective manner to all student-athletes across sports and genders. Concussion education should emphasize the diversity of symptoms, especially cognitive and behavioral symptoms. We must develop and disseminate evidence-based educational programs that are clinically proven to be effective in improving athletes' knowledge and behaviors.

Factors affecting the concussion knowledge of athletes, parents, coaches, and medical professionals

OBJECTIVES

To determine the predictors of knowledge and awareness of concussion symptoms and outcomes through a survey of athletes, parents of players and coaches in sports settings in Canada.

METHODS

A cross-sectional survey of athletic communities in Canada was conducted. Respondents' concussion knowledge score consists of responses to questions about the symptoms, diagnosis, and treatment of a concussion and the timing of return-to-sport post-concussion. The percentage of correct responses was defined as the "identification rate." The extent to which participant factors affected the scores was examined by univariate and multivariate analyses.

RESULTS

Respondents were able to identify a mean of 80.6% of symptoms. Cognitive symptoms were most commonly known, and mental health symptoms associated with concussion were least known, and health professionals, coaches, and those with a personal history of concussion had the highest levels of overall knowledge. Language, age, educational level, annual household income, and traumatic brain injury history were good predictors of better concussion knowledge.

CONCLUSION

Those designing and implementing interventions aimed at concussion management and prevention should ensure that younger, lower income, lower educational, non-English-speaking persons, and those without experience of traumatic brain injury or concussion be specifically accounted for in the design and implementation of interventions to prevent and treat concussion and mild traumatic brain injury.

Development and feasibility of an evidence-informed self-management education program in pediatric concussion rehabilitation

Background

Concussion is a considerable public health problem in youth. However, identifying, understanding and implementing best evidence informed recovery guidelines may be challenging for families given the vast amount of information available in the public domains (e.g. Internet). The objective of this study was to develop, implement and evaluate the feasibility of an evidence-informed self-management education program for concussion recovery in youth.

Methods

Synthesis of best evidence, principles of knowledge translation and exchange, and expert opinion were integrated within a self-management program framework to develop a comprehensive curriculum. The program was implemented and evaluated in a children’s rehabilitation hospital within a universal health care system. A retrospective secondary analysis of anonymous data from a program evaluation survey was used to evaluate program feasibility, to identify features of importance to program participants and to assess changes in participants’ knowledge.

Results

The program, “Concussion & You” includes a comprehensive, evidence informed, population specific curriculum that teaches participants practical strategies for management of return to school and play, sleep, nutrition, relaxation and energy conservation. A ‘wheel of health’ is used to facilitate participants’ self-management action plan. Results from eighty-seven participant surveys indicate that the program is feasible and participant knowledge increased in all areas of the program with the highest changes reported in knowledge about sleep hygiene, rest and energy conservation.

Conclusion

Findings indicate that “Concussion & You” is a feasible program that is acceptable to youth and their families, and fills a health system service gap.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1664-3) contains supplementary material, which is available to authorized users.

The Impact of a Concussion-U Educational Program on Knowledge of and Attitudes about Concussion

Background: The diagnosis of a sports-related concussion is often dependent on the athlete self-reporting their symptoms. It has been suggested that improving youth athlete knowledge and attitudes toward concussion may increase self-reporting behaviour. The objective of this study was to determine if a novel Concussion-U educational program improves knowledge of and attitudes about concussion among a cohort of elite male Bantam and Midget AAA hockey players. Methods: Fifty-seven male Bantam and Midget AAA-level hockey players (mean age=14.52±1.13 years) were recruited from the local community. Each participant completed a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey–Student Version immediately before and after a Concussion-U educational presentation. Follow-up sessions were arranged 4 to 6 months after the presentation, and assessed retention of knowledge and attitude changes. Results: Forty-three players completed all three surveys. Concussion knowledge and attitude scores significantly (p<0.01) increased from pre- to post-presentation by 12.79 and 8.41%, respectively. At long-term follow-up, knowledge levels remained significantly (p<0.01) higher than baseline by 8.49%. Mean attitude scores were also increased at follow-up; however, this increase was not statistically significant. Conclusions: A Concussion-U educational program led to an immediate improvement in concussion knowledge and attitudes among elite male Bantam and Midget AAA hockey players. Increased knowledge was maintained at long-term follow-up, but improved attitude was not. Future studies should investigate whether similar educational programs influence symptom reporting and concussion incidence. In addition, they should focus on how to maintain improved concussion attitudes.

The Relationship Between Concussion Knowledge and the High School Athlete's Intention to Report Traumatic Brain Injury Symptoms

Sports-related concussion or traumatic brain injury (TBI) is a frequent occurrence among high school athletes. Long-term and short-term effects of TBI on the athlete's developing brain can be minimized if the athlete reports and is effectively treated for TBI symptoms. Knowledge of concussion symptoms and a school culture of support are critical in order to promote the student's intention to report TBI symptoms. The purpose of this systematic review is to examine the relationship between the high school athlete's concussion knowledge and an intention to report TBI symptoms. One hundred eleven articles were retrieved and four articles met established criteria and were included in this systematic review. A link appears to exist between high school athlete concussion knowledge and an intention to report TBI symptoms. School nurses can provide a supportive environment and concussion knowledge to the high school athlete in order to ultimately facilitate TBI symptom reporting.

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.

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.

Social norms theory and concussion education

Secondary prevention of harm from sport-related concussion is contingent on immediate removal from play post-injury. To-date, educational efforts to reduce the prevalent risk behavior of continued play while symptomatic have been largely ineffective. Social norms theory may hold promise as a foundation for more effective concussion education aimed at increasing concussion reporting. The primary objective of this study was to assess whether perceived team concussion reporting norms would be less supportive of an individual's safe concussion symptom reporting behavior than objective team norms. Participants were 328 male and female US collegiate athletes. Written surveys were completed in person during the spring of 2014. Among both male and female athletes, team concussion reporting norms were significantly misperceived, with athletes tending to think that they themselves have safer attitudes about concussion reporting than their teammates. Perceived norms were associated with symptom reporting intention, independent of the team's objective reporting norm. A social norms approach to concussion education, in which misperceived group norms are corrected and shifted in the direction of safety, is an important avenue for program development and evaluation research aimed at the secondary prevention of harm from concussion. Implications for the design of this type of educational programming are discussed.

An examination of concussion education programmes: a scoping review methodology

OBJECTIVES

The primary purpose was to review the literature on concussion education programmes. The secondary purpose was to inform knowledge translation strategies for concussion researchers and practitioners.

DESIGN

Research on concussion education programmes is relatively new. As a result, the current study implemented a scoping review methodology, which is a type of literary search used to provide a preliminary assessment of the size and scope of a body of literature, as well as identify strengths, weaknesses and gaps in the research.

METHODS

A five-stage process for conducting a scoping review was followed for this study: (a) identifying the research questions, (b) identifying relevant studies, (c) identifying the study selection criteria, (d) charting the data and (e) reporting the results.

RESULTS

Concussion education programmes have been developed and implemented with populations ranging in age from 9 to 49 years and have used interactive oral presentations, educational videos and computer-based learning programmes. Although the content of these programmes varied, the topics generally addressed salient aspects of concussion injury and recovery. Quantitative instruments have been the preferred methods for assessment.

CONCLUSIONS

Education programmes aimed at improving participants' long-term concussion knowledge, behaviours and attitudes of concussions are needed. Researchers must consider using a knowledge translation framework to enhance concussion education programmes. The application of such a framework can lead to novel and interesting ways of disseminating information about concussive injury and recovery.

Engaging Teammates in the Promotion of Concussion Help Seeking

Concussion underreporting contributes to the substantial public health burden of concussions from sport. Teammates may be able to play an important role in encouraging injury identification and help seeking. This study assessed whether there was an association between beliefs about the consequences of continued play with a concussion and intentions to engage as a proactive bystander in facilitating or encouraging teammate help seeking for a possible concussion. Participants were 328 (male and female) members of 19 U.S. collegiate contact or collision sports teams. Athletes who believed that there were negative health or performance consequences of continued play with a concussion were significantly more likely than their peers to intend to encourage teammate help seeking, but not more likely to alert a coach or medical personnel. Additionally, athletes who believed that their teammates were more supportive of concussion safety were more likely to intend to engage as proactive bystanders in encouraging teammate help seeking. Exploring how to encourage bystander promotion of concussion safety is an important direction for future programming and evaluation research and may provide an opportunity to improve the effectiveness of concussion education.

Concussion Education in U.S. Collegiate Sport: What Is Happening and What Do Athletes Want?

Concussion education for athletes has the potential to play a role in reducing the health burden of concussions from sport by modifying individual risk-related behaviors. In U.S. collegiate sport, decisions about content and delivery of concussion education are left up to the individual institution. This may result in a high degree of variability in what educational materials athletes receive and is particularly problematic as few concussion education programs have demonstrated efficacy. Health educators can play an important role in working collaboratively with sports medicine clinicians to design and evaluate evidence-based concussion education materials for athletes that meet their learning needs. As a first step in this process, the present study characterizes the content, source, and delivery modalities of concussion currently being provided to U.S. collegiate athletes. It also describes the reported concussion education preferences of a sample of U.S. collegiate athletes. Participants were 789 athletic trainers from 276 schools and 325 athletes from four schools. Results indicated that education is most frequently provided by athletic trainers but that many athletes would also like coaches and physicians to be involved in this process. Athletes also indicated a preference for content provision across a range of topics, including athletic and academic consequences of continued play with a concussion. Implications for the design and delivery of concussion education for athletes are discussed.

Concussion: key stakeholders and multidisciplinary participation in making sports safe

As unstructured play declines, organized sports leagues have become a highly popular form of physical activity in young people. As concussive injuries are garnering increased media attention and public awareness, there is a growing concern for athlete safety. Although athletic trainers and physicians play a large role in keeping athletes healthy and safe, this article investigates nontraditional, multidisciplinary teams that are involved in promoting athlete safety, including the role of equipment makers, coaches, referees, governing bodies of sport, lawmakers, and fans. As opposed to a focus on diagnosing or managing concussive injuries, this article seeks to promote injury prevention strategies.

Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education

OBJECTIVE

This study aimed to evaluate whether preseason concussion knowledge and reporting intention predicted in-season concussion reporting behavior.

DESIGN

Prospective cohort study.

SETTING

Collegiate athletic facility of each participating team.

PARTICIPANTS

National Collegiate Athletic Association Division I men's ice hockey players in 1 conference of competition (n = 116).

INDEPENDENT VARIABLES

Intention to report symptoms of a "minor" concussion and concussion knowledge were assessed at preseason.

MAIN OUTCOME MEASURES

Postseason recall of non-report of postimpact symptoms.

RESULTS

Preseason concussion knowledge was not significantly associated with in-season reporting behavior. Intention to report concussion symptoms was significantly related to in-season reporting behavior. There was a significant interaction between the number of different symptoms experienced and both preseason reporting intention and in-season reporting behavior.

CONCLUSIONS

Evaluations of concussion education programs tend to measure concussion knowledge. The present findings suggest that reporting intention may be more strongly predictive of reporting behavior than concussion knowledge and should be included in evaluations of concussion effectiveness. New concussion education initiatives should consider targeting psychosocial constructs that increase reporting intention.

CLINICAL RELEVANCE

Sports medicine clinicians who are involved in evaluating concussion education programs should measure constructs other than just concussion knowledge. Intention, to report symptoms or to continue play while experiencing symptoms of a concussion, seems to be an important and feasible construct to include as part of proximal evaluations of education effectiveness.