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Athletes' Resistance To Self-Reporting of Concussion Continues Despite Increased Education

Survey finds college athletes still hide concussion symptoms in order to stay in the game

Athletes continue to underreport concussion (1) even when they know the signs and symptoms and that they risk serious injury if they continue to play with a concussion or return too soon from injury, say researchers in three recent studies. (2,3,4) 

The findings suggest that efforts to change the culture of contact and collision sports and the attitudes of athletes towards reporting concussion through education, don't appear to be working, at least so far.Football helmet

First up, a recent anonymous online survey of collegiate athletes revealed , despite increased concussion education, roughly the same degree of underreporting of concussion as in 2004.(2) 

Researchers at the University of Pennsylvania reported that, among all varsity athletes who responded within two weeks to an e-mail from Penn's head athletic trainer (former MomsTEAM expert, Eric Laudano):

  • 27% of athletes who self-identified as playing contact sports said they had hidden a concussion to stay in a game compared with 14% of athletes in noncontact sports;
  • 54% of contact athletes said they would be extremely unlikely or unlikely to report a concussion in a game situation; and
  • 30% of noncontact athletes said they were likely or extremely likely to report a concussion versus 20% for contact athletes.

"These findings were present despite strong educational efforts and knowledge of concussion symptoms among respondents and suggest that even educated athletes may not have changed their attitudes toward reporting concussion," the study noted.

Following these findings among college athletes comes a May 2013 study from researchers at Cincinnati Children's Hospital (3) of 120 high school football players, 30 of whom had suffered a concussion. The good news was that three quarters of those surveyed (82 out of 120) reported receiving prior concussion education, and that most could correctly recognize the principal symptoms of concussion:

  • headache (93.3%); 
  • dizziness (89.2%); 
  • difficulty remembering (78.3%); 
  • sensitivity to light/sound (78.3%); 
  • difficulty concentrating (75.8%); and 
  • feeling in a fog (52.5%)).

Also encouraging was that 9 out of 10 recognized the risk of serious injury if they returned to play too quickly.

But here's the bad news: 

  • an astounding 91 percent felt that it was okay for an athlete to play with a concussion
  • 75 percent said they would play through any injury to win a game
  • 53 percent said they would "always or sometimes continue to play with a headache sustained from an injury,"
  • Only 54 percent would "always or sometimes report symptoms of a concussion to their coach," and
  • Only 4 in 10 would tell their coach immediately if they had concussion symptoms.

Most recently, a study by researchers at Wake Forest, the University of North Carolina at Chapel Hill, and A.T. Still University in Mesa, Arizona (4), found that, while athletes are generally knowledgeable about the signs and symptoms of concussion, there is a "gross underreporting" of concussion events, with a large proportion of those surveyed indicating that they continued to participate in both games and practices while experiencing symptoms. Football player at locker with helmet

"Most strikingly," writes Johna Register-Mihalik, Ph.D, LAT, ATC,  Adjunct Assistant Professor in the Department of Exercise and Sport Science at the University of North Carolina at Chapel Hill, "athletes only indicated reporting 13% of events they considered bell ringers, which were likely concussive injuries." The concern, she writes, is that "athletes not reporting these bell-ringer events may have continued to participate or returned to participation too early, predisposing them to further injury." The underreporting rate of approximately 40% for perceived concussions was not substantially better than the 50% underreporting rate found in previous studies over the last decade.(1,5,6)

Consistent with the other studies, the reasons athletes gave for not reporting possible concussions were that they:

  • did not think the injury was serious enough to report (70.2%);
  • did not want to be removed from the game (36.5%);
  • did not want to let down teammates (27.0%)
  • did not want to let down coaches (23.0%);
  • did not know the event was a concussion (14.9%); or
  • did not want to be removed from practice (13.5%).

Unfortunately, most recent data, collected by from high school football players in Ohio and the Boston area after the 2014 season by researchers from Nationwide Children's Hospital, Columbus, Ohio, Harvard Medical School and Boston Children's Hospital (11) doesn't much progress in moving the dial towards a higher percentage of self-reporting.  Only slightly more than half (56.4%) of those completing the survey who had sustained a concussion during the 2014 season had reported it, with the proportion of first-stringers who reported lower than non-first stringers (49.3% and 73.3% respectively).

Same ol', same ol' 

The reasons for their failure to honestly report? No surprises here either. Of the players who did not report his or her concussion, the most common reasons, once again, were, first, "feeling it wasn't a serious injury (56.9%), and second, "didn't want to be pulled from competition (47.7%).

Thus, despite over a decade of education, by MomsTEAM and others, around half - and probably a lot more (the fact that only 38% of athletes in the sample responded to the questionnaire may reflect a selection bias; those who did not respond may have done so because they did not want to admit to their failure to report) - the dial hasn't moved in any signiificant way from the 50% who didn't report back in 2004.

Personal experience is same

All these findings are not at all surprising to me, based on my experience during the filming of MomsTEAM's documentary, "The Smartest Team." Nearly every football player, not to mention the athletic trainer, coaches, and parents, I interviewed for the film freely admitted that they would not self-report concussion symptoms.

Here is just a sampling of what I was told: 

  •  "I've got a pretty good rapport with the athletes here at Newcastle. They know I'm not trying to keep them out, or keep them from playing. ... There are kids who take hits all the time, they don't come and tell me, until someone else comes and tells me, and I don't know anything about it." (Damon Glass, Newcastle certified athletic trainer)
  • "Their biggest fear is missing out." (Dale Berglan, Newcastle Athletic Director)
  • "I have a friend on the line. He's the center. We were at practice one day, and he seemed really out of it. So, I told coach, and he got really mad. But I know it was going to help him in the long run." (Matt Meyer, Newcastle player).
  • "They don't want to come out. They want all the playing time they can get. They don't want to come out for a couple of plays." (Colin Black, Newcastle player).
  • "Unless it's really, really bad, and knocks me out. I probably won't play through that. But if I can get up and walk away from it, I'll probably keep playing. You see some dots, but then go away. So just keep playing through it. It's my senior year." (Cody Womack, Newcastle player)
  • "It's my senior year. You can't afford to miss any games. You have to make the most of it, while you still can. 'Cuz as of now we only have two games promised left. And if we don't win one of the nest two, then we don't go to playoffs." (Justin Ledford, Newcastle player)
  • "The football game. Making the playoffs, or the championship. That's one night. Are you going to take that, or you are going to take a lifetime of success?" (Robin Gibson, football mother)
  • "They don't like to sit out because they are afraid they are going to lose their position. Unfortunately, that happens. We have a great team with a lot of great players, and if you are out any length of time, you have the potential of not being to start your position." (Chastity Corbin, football mother).

Are impact sensors a partial solution?

All the recent studies are also consistent with a 2010 ESPN poll of players, coaches, parents and athletic trainers in 23 states (7) which found that players - the ones whose brains are being rattled and who are putting themselves at risk of adverse long-term health consequences from concussions - are still the group least concerned about concussions.

When asked whether, if a star player got a concussion, they would rather lose the state title game as he sat out than win it because he chose to play with a concussion, more than half (54.1%) of the 300 players in the ESPN survey said they would play the star compared to 9% of athletic trainers, 6.1% of parents, and 2.1% of coaches.

All of this is leading an increasing number of experts to argue that the best way to address the problem of underreporting may be to try a multi-pronged approach: try to change the culture through education - which, as in trying to change any culture, especially as one as entrenched and likely hard-wired as the win-at-all-costs culture of resistance to injury reporting, is going to take a long, long time - and, at the same time, perhaps not rely so heavily on the athletes themselves, game officials or sideline observers to identify concussed athletes, but to use technology in the form of impact sensors to improve identification of athletes with possible concussion and remove them from play for concussion assessment on the sports sideline. (8,9,10)

The scientific community, however, is sharply divided over the value of sensors in improving the rate at which athletes suspected of having sustained a concussion are identified on the sports sideline. Many argue that impact sensors, at least at this point, are not the answer.  Johna Register-Mihalik, Ph.D, LAT, ATC,  Adjunct Assistant Professor in the Department of Exercise and Sport Science at the University of North Carolina at Chapel Hil, and lead author of one of the most recent study finding "gross underreporting" of possible concussions by high school athletes (4), tells MomsTEAM that she does not recommend their use in concussion detection because "the science, although a growing field of information, is just not quite there in how these may best be used from a clinical standpoint and across all sport settings."

She notes that, "As it stands, there is no absolute threshold for concussive injury and while these sensors may identify individuals who receive a certain type of hit or impact, we do not yet know if those impacts not identified by a set threshold may lead to concussion."  Register-Mihalik expressed concern that the sensors "may provide a false sense of security, in that 'if the sensor didn't go off, I must not have a concussion.'" (although she found it "encouraging"  that players in The Smartest Team were receptive to having sensors in helmets because they would make it harder for them to hide their concussion symptoms,)

"There is certainly potential for this type of technology to have great implications in the identification of concussion as the science advances," says Register-Mihalik, but, she argues, "we need more scientific and unbiased evidence of their ability to detect concussion before they are widely used and recommended in all settings. Until that time, there are some good examples of identification techniques of having trained observers, a parent advocate and continuing to promote concussion education that we know will increase identification rates.  

As I have also found working with a variety of different impact sensors over the past four football seasons, both at the high school level and the past two seasons at the youth level, they are still a largely unproven technology, and their cost has not come down, and their reliability has not gone up, to the point where widespread adoption is practical or likely anytime soon.  In the meantime, trying to change the culture, from one of resistance to reporting, to one of safety, to working with athletic trainers, coaches, parents, and athletes to create an enviroment in which athletes feel safe to honestly self-report experiencing concussion symptoms - to not just increase concussion knowledge but to translate that knowledge into action by changing attitudes by all stakeholders towards concussion reporting.   

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

2. Dziemianowicz M, Kirschen MP, Pukenas BA, Laudano E, Balcer LJ, Galetta SL. Sport-Related Concussion Testing. Curr Neurol Neurosci Rep 2012 (published online July 13, 2012)(DOI:10.1007/s11910-012-0299-y)(citing unpublished data).

3. Anderson B, Pomerantz W, Mann J, Gittelman M. "I Can't Miss the Big Game": High School (HS) Football Players' Knowledge and Attitudes about Concussions. Paper presented at the Annual meeting of the Pediatric Academic Societies, Washington, D.C. May 6, 2013.

4. 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).

5. 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.

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

7. "Concussion Confidential" ESPN The Magazine (http://sports.espn.go.com/espn/news/story?id=5925876)(accessed December 21, 2010).

8.  Greenwald R, Chu J, Beckwith J, Crisco J. A Proposed Method to Reduce Underreporting of Brain Injury in Sports. Clin J Sport Med 2012; 22(2):83-85.

9. Kutcher J, McCrory, Davis G, et al. What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery? Br J Sports Med 2013;47:299-303.

10. Broglio SP, Eckner JT, Surma T, Kutcher JS. Post-Concussion Cognitive Declines and Symptomatology Are Not Related To Concussion Biomechanics in High School Football Players. J Neurotrauma 2011;28:1-8.

11. Research Abstract. "The Reporting of Concussions Among High School Football Players, an Updated Evaluation." Minor JL, MacDonald J, Meehan WP. Presented at American Academy of Pediatrics National Conference and Exhibition, Washington, D.C. October 24-27 (most recently accessed October 23, 2015 at https://aap.confex.com/aap/2015/webprogrampress/Paper32146.html)

Most recently updated October 23, 2015