A survey of high school athletic directors, coaches, and certified athletic trainers in Michigan (1) finds that, while concussion education is common in football, less than half of girls' soccer players receive such education, this despite the fact that the sport also has a high concussion rate.
Researchers from the Detroit Medical Center Sports Medicine in Novi, Michigan surveyed athletic directors, athletic trainers, and head coaches in football, boys' and girls' soccer, and boys' ice hockey at 235 Michigan high schools to test the hypothesis that there would be differences in concussion management and awareness among the different sports.
They were right.
While all three groups reported that pre-season concussion education awareness meetings were usually held in football, only about half of boys playing high school soccer received such education, falling to less than half (47-48%) for girls' soccer.
Equally troubling, although most ATs reported using sideline screening tools in evaluating suspected concussion (about 75% of the time, across the four sports studied), the use of sideline screening tools reported by coaches was significantly lower for football (55%) and hockey (50%), and fell off sharply for soccer, where coaches used screening tools only 30% of the time in boys' soccer and at an alarmingly low 17% of girls' soccer games and practices.
"To appropriately evaluate and treat concussions, an athletic program should have a clearly defined concussive injury policy ... [so that] all staff members [are] well informed and prepared to take the proper steps within the school's guidelines," says the study. Yet, written concussion management policies were only in place, reported survey respondents, between 50% and 62% of the time.
More education/written policy needed
"Concussion education is well promoted in football, but should be reevaluated in soccer and hockey," said lead author Amanda Esquivel, PhD. "The most education about head injuries and concussions is available for sports [with] the highest rates of concussion, such as football," she said, but it was "important to ensure that female players are provided with a concussion education program as they have proven to be more likely to sustain a concussion than male players participating in the same sport."
The authors also recommended promoting the use by high school coaches in boys' hockey and boys' and girls' soccer of sport-specific concussion education materials, such as the CDC's "Heads Up" tool kit for coaches, which a 2010 study (2) reported, resulted in increased concussion education, with 84% of coaches who ordered the kit providing concussion education to their athletes, and 90% reporting using at least of one of the materials from the kit), and which, the study found, prompted more than half to view concussions more seriously, and led four in ten (38%) to make changes in their prevention and management strategies.
Noting an earlier study finding a lack of compliance with graduated return-to-play guidelines among high school students (3), and another finding that student-athletes returning to play before full recovery may be at risk of further injury (including, in rare cases, catastrophic injury or death from second impact syndrome) (4), the authors were encouraged by their finding that a majority of respondents required players to be cleared by a physician or neuropsychologist prior to returning to play. "However, without a written policy, this may be difficult to enforce. Continuing efforts need to be made to educate coaches, parents, athletes, and policy makers on the consequences of returning athletes to play prematurely after concussive injuries," they wrote.
Significantly, Esquival noted that the study was conducted before Michigan's enactment in October 2012 of a so-called Zackary Lystedt law requiring all athletes to be educated/trained about concussions, that athletes with suspected concussions be immediately removed from practice or game participation, and that written clearance be obtained from a licensed health care professional before return to play. "It is possible that this new law could affect the results of this study. A follow-up study could examine whether this law helps to increase concussion education among sports other than football," she wrote.
The need for concussion education in girls' soccer is critical, as two-time Olympic gold medalist and former U.S. women's national soccer team member, Cindy Parlow, recently told MomsTEAM's Brooke de Lench. Parlow, who suffers from post-concussion syndrome, summarized the need for such education this way: "I think once you know better, you do better. And we just didn't know better when I was playing. You didn't really think twice about seeing stars after you got hit in the head. I think now, as we educate more of our athletes, we make sure that they know the symptoms and know that it's not normal to see stars."
Two recent studies suggest that concussion education works.
In the first study (5), researchers at the University of Washington evaluated the impact of concussion legislation on concussion awareness among parents, coaches, and players a year after the May 2009 enactment in that state of its pioneering Zackary Lystedt law. They found that 96% of respondents understood that concussions were a form of traumatic brain injury, and 90% said they would delay an athlete's return to play when symptoms of concussion were still present. Fewer individuals understood the return-to-play guidelines contained in the law, including the requirement of written clearance from a health care professional with concussion expertise (73%) or that a parent could not clear the athlete for return to play under the new law (88%).
In the second study (6), Boston researchers tested the effectiveness of a novel concussion education program from the Sports Legacy Institute called SLICE (Sports Legacy Community Concussion Education) in which medical and health-related students delivered age-specific presentations to student-athletes. They found that students displayed significant improvements in their concussion knowledge after attending presentations, with females and older students (aged 13 to 15) showing the most improvement comparied to their pre-presentation knowledge.
Study details
Preseason concussion awareness education
Coaches: According to coaches, concussion education was provided as follows:
- 97% of the time for football players
- 65% for boys' hockey
- 57% for boys' soccer
- 47% for girls' soccer.
Athletic trainers: The percentage of ATs who reported that concussion education was provided were:
- 76% for football
- 70% for hockey
- 56% for boys' soccer
- 48% for girls' soccer
Athletic directors: Three-quarters (72%) of athletic directors stated that their school had informational material on concussion education.
Familiarity with concussion guidelines
The percentage of coaches, ATs and athletic directors who reported being very or somewhat familiar with (a) the state athletic association's protocol for implementation of the national sports-concussion guidelines (7), (b) the 2008 Zurich concussion consensus statement (8), (c) the "Heads Up" concussion kit from the Centers for Disease Control and Prevention (CDC)(2) (d) the National Athletic Trainers' Association's 2004 Position Statement on the management of sports-related concussions (9), and (e) the National Federation of State High School Association 's (NFHS) online concussion course, were as follows:
| State Association Guidelines | Zurich consensus statement |
CDC Heads Up Kit |
NATA Position Statement | NFHS Online Course | |
| Coaches | 95% | 25% | 35% | 58% | 70% |
| Athletic Trainers | 93% | 60% | 70% | 98% | 50% |
Written concussion management policy
Asked whether their school had a written policy in place to manage concussions, 50% of athletic directors, 62% of coaches, and 52% of ATs said yes. The written policy was based on the following:
- State Athletic Association guidelines: 53%
- NATA: 16%
- NFHS guidelines: 11%
- CDC: 6.2%
- Zurich consensus statement: 5%
- Other/not sure: 6.7%
Baseline testing
Just one fifth of coaches (20%) and four in ten ATs (37%) reported using baseline neurocognitive evaluations, numbers lower than the national average for high schools with ATs.(10)
Use of Sideline Screening Tools| Football |
Ice Hockey |
Boys' Soccer |
Girls' Soccer | |
| Coaches | 55% | 50% | 30% | 17% |
| Athletic Trainers | 74% | 74% | 78% | 72.5% |
All participants in the survey agreed that a player who suffered a concussion cannot return to play the same day. Parents are also notified when a player suffers a concussion, with 35% of athletic directors, 49% of coaches, and 18% of ATs also saying they reported concussions to the state athletic association.
| Players referred to physician after concussion | Physician clearance before return to play required | |
| Athletic directors | 98% | 95% |
| Coaches | 90% | 89% |
| Athletic Trainers | 93% | 90% |
Begging the question
A steady stream of studies in recent years makes it clear that concussions in high school girls' soccer are a serious problem. The most recent comprehensive study (11) reports a concusson rate almost twice as high as boys' soccer (3.4 per 10,000 athletic exposures versus 1.9 per 10,000 AEs), and in a virtual tie with girls' lacrosse (3.5 per 10,000 AEs) and behind only football (6.4 per 10,000 AEs), boys' ice hockey (5.4 per 10,000 AEs), and
The study's finding that high schools, at least in Michigan, do little concussion education in girls' soccer, thus begs the question of why?
1. Esquivel A, Haque S, Keating P, Marsh S, Lernos S. Concussion Management, Education, and Return-to-Play Policies in High Schools: A Survey of Athletic Directors, Athletic Trainers, and Coaches. Sports Health: A Multidisciplinary Approach. 2013;20(10). Published online ahead of print as doi:10.1177/1941738113476850 (accessed February 23, 2013)
2. Sarmiento K, Mitchko J, Klein C, Wong S. Evaluation of the Centers for Disease Control and Prevention's concussion initiative for high school coaches: "Heads up concussion in high school sports."J Sch Health2010;80(3):112-118.
3. Yard EE, Comstock RD. Compliance with return to play guidelines following concussions in US high school athletes, 2005-2008. Brain Inj. 2009;23(11):888-898.
4. Byard RW, Vink R. The second impact syndrome. Forensic Sci Med Pathol.2009;5(1):36-38.
5. Shenouda C, Hendrickson P, Davenport K, Barber J, Bell KR. The effects of concussion legislation one year later - what have we learned: a descriptive pilot survey of youth soccer player associates. PM R. 2012;4:427-435.
6. Bagley AF, Daneshvar DH, et. al. Effectiveness of the SLICE Program for Youth Concussion Education. Clin J Sport Med 2012;22(5):385-389.
7. Michigan High School Athletic Association. Health and Safety. http://www.mhsaa.com/Schools/HealthSafetyResources.aspx.
8. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M. et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br.J. Sports Med. 2009: 43:i76-i84.
9. Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, Valovich McLeod T. National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion. J Athl Tr 2004;39(3):280-297.
10. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011)
11. 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.
