Sports-related concussion

Methods

The link to a 35-question online survey was e-mailed to all varsity athletes (n = 919) at the University of Pennsylvania (Division I school) by the Head Athletic Trainer. Responders were provided a $5 Starbucks gift card in exchange for participating in the survey. The University of Pennsylvania Institutional Review Board approved all protocols and communications as acceptable for the student population surveyed, including the $5 Starbucks gift card incentive.

The survey contained questions on concussion history, including specific symptoms, number of times diagnosed, and whether they had missed academic or athletic time (appendix e-1 at neurology.org/cp). To assess concussion education, participants were asked about knowledge of symptoms and long-term sequelae, and whether or not physicians or athletic trainers had discussed risks. Finally, participants were asked about their likelihood of reporting a concussion during a future game using a Likert scale format with 1 being “extremely unlikely” to 5 being “extremely likely” to report symptoms of concussion to an athletic trainer or coach or teammate during a game.

Data analyses and calculations were performed using Stata 12.1 statistical software. Proportions of athletes with particular responses to questions were the primary summary measure used, along with 95% confidence intervals (CI) for Likert scale responses (figure 1). The Pearson linear χ² test was used to compare proportions of athletes with vs without concussion history as well as between sexes with respect to dichotomous survey responses.

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Figure 1 Likelihood of athletes to report a concussion to a coach or athletic trainer according to history of concussion (A) and sex (B)

*Error bars indicate 95% confidence intervals on the proportions of athletes in each response category.

Results

Characteristics and survey responses for the 262 Penn athletes who completed the survey (29% response rate) are shown in the table.

Attitudes toward reporting

Overall, 22% of athletes indicated that they would be unlikely or very unlikely to report concussion symptoms to a coach or athletic trainer in the future. Among all athletes in the cohort (those reporting and not reporting a history of concussion), the anticipated likelihood of reporting symptoms of concussion to a coach or athletic trainer (self-reported by the athletes on a Likert scale with 1 = extremely unlikely to 5 = extremely likely) was less among athletes with a history of concussion (figure 1A) and among male respondents (figure 1B). These groups had a greater likelihood of choosing “unlikely” responses (extremely unlikely or unlikely) compared to those without concussion history or female athletes in this cohort. Male respondents were similarly more likely to say they would be “unlikely” to report symptoms to a teammate compared to female athletes (19/119 [16%] vs 8/145 [5%], p = 0.005, χ² test, figure 2B). Stated differently, athletes who reported a prior history of one or more concussions, and male athletes, were more likely to choose survey responses of “unlikely” or “extremely unlikely” for the 2 questions regarding future likelihood of reporting symptoms of concussion to a coach or trainer or to a teammate. In logistic regression models, male sex and history of concussion were independent predictors of unlikelihood of future reporting (p = 0.01 for each variable). Among athletes reporting a history of concussion, 30/70 (43%) indicated that they had hidden symptoms of a concussion to stay in a game.

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Figure 2 Likelihood of athletes to report a concussion to a teammate according to history of concussion (A) and sex (B)

*Error bars indicate 95% confidence intervals on the proportions of athletes in each response category.

Discussion

Data from this anonymous online survey suggest that there may be a substantial degree of underreporting of concussion among athletes in a collegiate cohort. These findings were present despite most athletes acknowledging that they have been formally educated about the risks of concussions. While the importance of such education has been emphasized, particularly recently, there has been little work to date on establishing a link between concussion knowledge and attitudes and the likelihood of athletes reporting symptoms to athletic trainers, coaches, or teammates.

Exploratory analyses of our survey data suggest that athletes’ likelihood of future reporting, especially to teammates, may be lower for male athletes and among those with a history of concussion. In our collegiate cohort, 43% of athletes with a history of concussion reported that they had knowingly hid a concussion to stay in a game, and 22% of athletes overall indicated that they would be unlikely or very unlikely to report concussion symptoms to a coach or athletic trainer during a game in the future. Previous studies involving athletes have suggested that between 50% and 75% of sports-related concussions go unreported.⁶ Our data suggest that some athletes even with formal education about the negative consequences of concussion may not have changed their attitudes toward reporting. Importantly, athletes in our cohort indicated that they would be less likely to hide symptoms of a concussion from a teammate (only 10% choosing responses of “unlikely” or “extremely unlikely” in this setting). This finding suggests that there is potential value in including peers in future educational efforts. Future surveys could capture potential overreporting or symptoms unrelated to concussion in order to assess the role for survey-taking differences in evaluating responses and the recent attention focused on the potential consequences of concussion.

Perceptions and attitudes regarding concussion reporting among athletic trainers, coaches, and parents are likewise important for shaping the culture surrounding concussions among collegiate athletes. While providing education is clearly important, in our group the education they received did not necessarily motivate them to be unanimously resolute about future reporting of symptoms. Knowledge of concussion may not be the primary problem leading to underreporting; this is consistent with recently published and ongoing investigations of student athletes implicating non-education-related factors, such as coach approachability.¹² Perhaps somewhat similar to efforts to educate consumers about the possible long-term effects of any activity involving risk, concussion education efforts could not only work toward building trust, but also aim to better motivate athletes to consider the balance of prevention and immediate reward. Incorporating the efforts and research of those in the population and public health fields, in combination with more detailed epidemiologic studies, may help us to refine and target these important educational programs.

As with any study that uses survey methods to assess self-reported history, attitudes, and estimates of future behavior, there is potential for bias. To the extent that our survey response percentage was close to one-third of those e-mailed (n = 262 completed, 29%), this rate was similar across the sports surveyed. As such, our data represent a reasonable cross-sectional sample of athletes in collegiate athletics at an Ivy League university. With the $5 Starbucks gift card incentive, our response rate is similar to that noted in studies of college students and recent college graduates who were offered small up-front rewards (college logo pen, 29%),¹³ yet lower than response rates when a larger, prepaid incentive ($10) was offered (42%).¹⁴ Frequencies for the top sports listed in the recently published American Academy of Neurology guideline (football, soccer, and basketball)⁷ were similar to our cohort with regard to relative proportions of athletes with concussion. Our survey did not include ice hockey players since this is classified as a club sport at Penn. However, our cohort did include lacrosse players, who have a high rate of concussion according to National Collegiate Athletic Association data (unpublished). The present cohort therefore likely reflects the collegiate population at large despite the <1/3 survey return rate.

While the potential effects of bias are lessened by greater response rates, athletes with a tendency for “risk taking” may have been more likely to respond to the online survey. Our response rate, although similar across sports surveyed, may therefore be reflective of underreporting overall as athletes may not have wanted to discuss their previous history or future intentions, even in the context of an anonymous survey. It is possible that our survey actually underestimated the likelihood of underreporting if in fact most athletes who feel strongly against telling a coach, athletic trainer, or teammate about symptoms did not respond. Societal avoidance of the possibility of concussion being a serious health concern may have played a role. Furthermore, while the highest incidence rates of concussion in collegiate competitions are in football,⁷ this sport accounted for only 8.5% of respondents in our survey who reported a prior history of concussion. This suggests that underreporting or avoidance of survey participation using an e-mail or online format may be sport-dependent. A more comprehensive survey, with greater representation of injury reporting in sports with the highest rates of concussion, is likely to be achievable by an in-person administration with de-identified response forms collected by research staff not associated with team play decisions.

Collaborations are now being formed among Ivy League institutions as well as among larger leagues within collegiate athletics to not only study the epidemiology of sports-related concussion and its potential outcomes, but to design educational efforts that will provide effective counsel to the next generations of athletes. While educating athletes will be a crucial first step, perceptions and attitudes regarding concussion reporting among athletic trainers, coaches, and parents may be even more important for shaping the culture of concussion at all levels of play.