Underreporting of Concussion By High School Athletes Continues Despite Increased Education

Multi-pronged approach to underreporting recommended

Recognizing that underreporting of concussion is a "multifaceted" and "overwhelming" problem, with knowledge and attitude both appearing to influence reporting behaviors, the study authors recommend taking a multi-pronged approach to improving reporting rates, including:

1. Increasing education about concussion symptoms.

Especially needed is education about less common symptoms, such as nausea (cited as a symptom by 31.4% of high school athletes [8]) and amnesia (cited as a symptom in 23.4% of concussions in another recent study [9]).  "These symptoms, as well as the other symptoms, should be emphasized in educational efforts," Register-Mihalik told MomsTEAM, "due to their connection with potential delayed recovery time [as both have been linked in a recent study [8] with increased risk of prolonged symptoms], as well as the impact that these symptoms have on overall quality of life.  [Because] nausea is often associated with other conditions [such as dehydration or overeating before an event], helping young athletes connect this symptom to a potential concussive injury is also important.  Amnesia is a difficult symptom, and many young athletes may not fully understand what amnesia as a term actually means, so using age-appropriate terminology when assessing and discussing concussion, such as 'trouble remembering things' or 'memory problems' may also be helpful."

Study co-author McLeod agreed that, while all concussion signs and symptoms should be discussed in educational efforts, "We probably could do a better job of educating about the immediate and most prevalent symptoms, but pay equal attention to those that occur less often, may be indicative of decline in [mental] status [which may indicate a more serious brain injury], and those that may be late manifesting so that concussions are not missed by just focusing on a few signs and symptoms. Identifying symptoms that might be predictive of delayed recovery or poorer prognosis is one area of research that I believe will continue to emerge in the coming years;"

2. Fostering increased understanding among clinicians, parents, coaches, and athletes of:

• the serious nature of concussive injuries.  "Despite the perception of concussions being mild, high school athletes with mild concussions may experience neurocognitive deficits and symptoms that persist beyond day of injury," the study notes.
• the need to report bell-ringing events that might be considered so 'mild' that they go unreported;
• the risks associated with continuing to play, including delayed recovery [16] or even catastrophic consequences, such as second impact syndrome.

3. Increasing education of coaches. Such education is especially needed in recognition of the role the coach often plays in initiating medical care in the event an athlete is injured; the fact that, while coaches do not have the same training as medical professionals and reporting to a coach is admittedly very different from reporting to a medical professional, coaches are often the authority figure to whom individuals turn to report a concussion or other injury; and the fact that fewer than half of all U.S. high schools have access to a certified athletic trainer. [11]  [Note: more recent data from the NATA [17] suggest that the percentage now stands at over 60%].

4. Creating a safe environment which encourages reporting of concussion events by:

• educating the community, coaches, parents, and athletes about concussion;
• helping athletes to understand they are not alone in experiencing concussion; 
• providing forums (such as at pre-season concussion education meetings) for individuals, especially those respected in the athletic community, to speak out about concussion and why these injuries should be reported and managed properly; and
• developing awareness programs designed to "create an environment that rewards positive concussion-care seeking behaviors,[13] such as reporting an injury or removing one's self from play when experiencing concussive symptoms ... [such as] the athletic director at the school having medical providers from the community come into the school to talk about concussion or a coach being understanding and supportive when an athlete reports concussive symptoms and is unable to continue playing, especially in front of other athletes." [10]

"Clinicians, parents, and coaches should make concussion education and awareness a priority," concludes Register-Mihalik and her colleagues, "and address factors to provide a more optimal concussion-reporting environment."  Both are needed, because, as acknowledged in the study, "knowledge alone does not equal behavior."  "Individuals may understand and believe that concussion is a serious injury and even a medical concern; however, if they also believe that their peers or coaches will take issue with their reporting their injury or that they may lose substantial playing time, they may still choose not to report the injury."   "Parents also play a key role in driving coaches to be aware and to create this environment at home," Register-Mihalik told MomsTEAM.

Indeed, a 2014 study [15] provides support for Register-Mihalik's conclusions, finding that concussion knowledge was not significantly associated with in-season reporting behavior, and that a better predictor of in-season reporting behavior was intention to report symptoms of a minor concussion, with increasing odds of reporting as additional symptoms were sustained.  The study's authors acknowledged, however, that it was possible that for some populations (eg, younger athletes aor athletes early in their sporting careers), concussion knowledge as it is presently measured may be an important predictor of reporting behavior.  

Valovich McLeod agreed with Register-Mihalik that "There is promise to make these changes happen faster with educational efforts and legislation; however, there are still coaches and parents who have an old-school mentality regarding concussions. Pressure to play needs to be taken off kids in order for them to feel comfortable reporting their signs and symptoms of a possible concussion."  

5. Future research to explore how external factors influence reporting among high school athletes, such as

• coach, parent, and teammate pressures
• the influences on reporting among high school athletes (Note: the 2013 study by the same authors involving the same study sample [10] found that coaches and teammates are the strongest influences on an athlete's intention to report concussion; although the study did not survey parents, the student-athletes surveyed "indicated that what their parents thought about reporting was an important social factor when deciding to report concussive symptoms");
• knowledge and attitudes in other high-risk sports, such as ice hockey, basketball, and wrestling.  The combination of the fact that 42.9% of the participants in the current study were football athletes, that the return rate of the survey was low (10%), and was derived from a so-called "convenience" sample, limited generalizing the study's findings to the general population); and
• when the athletes reported the event (immediately after injury or at a later time)(a subject explored in a 2014 study.[15]

Bottom up, trickle down, long way to go

"Although our study encompassed only 1 convenience sample of athletes, the major findings illustrated the importance of increased athlete knowledge, more favorable athlete attitude, and context of reporting concussion among high school athletes," wrote Register-Mihalik. 

"We highlighted the importance of addressing multiple factors to increase reporting of possible concussive injuries. In addition, we highlighted the need for multifactorial interventions in the high school setting to address these risky behaviors."

"We are certainly seeing changes at many levels of sport in the right direction, but still have a long way to go." Register-Mihalik told MomsTEAM.  "I do think there are things we can continue to do in the here and now that will result in immediate effects, especially when local individuals are advocates for concussion education and sport safety. However, it is true that historically culture change does take years."

"One approach ... is to start at the youngest ages of sport so that individuals carry good attitudes about sports safety and concussion throughout their lives. It is also important that, in addition to this bottom up approach, that we have things trickle down from the top so that information is flowing in both directions, creating a more comprehensive safety network across sport."

"Now that we have many people attentive to concussion, we need to make sure the right message is getting to the right people, in communities of all types. This involves community networking including parents, coaches, administrators and medical professionals at the local, state, regional and national levels working together," Register-Mihalik concluded.

Athlete Attitude

1. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW.  Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study.  J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)

2. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13-17.

3. Echlin PS, Tator CH, Cusimano MD, et al. A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.  Neurosurgery Focus. 2010;29(5):E4.

4. Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concuission among university football and soccer players.  Clin J Sport Med 2002;12(6):331-338.

5. Kaut KP, DePompei R, Kerr J, Congeni J. Reports of head injury and symptom knowledge among college athletes: Implications for assessment and educational intervention.  Clin J Sport Med 2003;13:213-221.

6. Valovich-McLeod TC, Schwartz C, Bay RC. Sport-related concussion misunderstanding among youth coaches. Clin J Sport Med. 2007;17(2):140-142.

7. Rosenbaum AM, Arnett PA. The development of a survey to examine knowledge about and atittudes toward concussion in high school students. J Clin Exper. Neuropsych. 2010;32:44-55.

8. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med 2012;40(4):747-755.

9. Chrisman SP, Rivara FP, Schiff MA, Zhou C, Comstock R.D. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Injury 2013;27(1):1-9.

10. Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM.  Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives.  Brain Injury 2013;27(7-8):878-886.

11. Waxenberg R, Satloff E. Athletic trainers fill a necessary niche in secondary schools.  National Athletic Trainers' Association: 2009.  Available at: http://www.nata.org/NR031209. 

12. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)

13. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.

14. Delaney JS, Lamfookon C, Bloom GA, Al-Kashmiri A, Correa JA.  Why University Athletes Choose Not To Reveal Their Concussion Symptoms During A Practice Or Game.  Clin J Sports Med. 2014;0:1-13; doi: 10.1097/JSM.0000000000000112 (published online ahead of print with post-publication corrections, June 19, 2014). 

15. Kroshus E, Baugh CM, Daneshvar DH, Nowinski CJ, Cantu RC. Concussion Reporting Intention: A Valuable Metric for Predicting Reporting Behavior and Evaluating Concussion Education. Clin J Sport Med. 2014; Post Author Corrections: July 21, 2014
doi: 10.1097/JSM.0000000000000137. 

16.  Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM.  "Playing Through It": Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. J Athl Tr. 2016;51(5):000-00 doi: 10.4085/1062-6050-51.5.02 (published online ahead of print)

17. Pryor RR, Casa DJ, et al. Athletic Training Services in Public Secondary Schools: A Benchmark Study. J Athl Tr. 2015;50(2):156-162. 

Most recently revised and updated April 30, 2016