Concussion is a widespread pathology affecting many student-athletes across sports, competition levels, and sexes.1,2 Emerging literature indicates a potential growing concussion prevalence.2,3 Previous studies indicate approximately 50% of concussions go unreported across high school, collegiate, and professional sport levels for reasons such as: the individual did not know the injury was serious enough, did not want to let the team or coach down, did not want to be removed from athletic participation, or simply did not recognize the signs and symptoms.4–13 To report a possible concussion, student-athletes must possess a general knowledge and comprehension of the associated signs and symptoms. Student-athletes lacking knowledge may not recognize their concussions and consequently be incapable of reporting.
Self-reporting signs and symptoms are a keystone in concussion assessment and the strongest diagnostic tool in the multidimensional assessment battery.14–16 One limitation with signs and symptoms and other assessment techniques is that they rely on student-athletes choosing to report potential concussions to health care providers because the signs and symptoms of concussion are not always visible. If student-athletes cannot identify their signs and symptoms, they may continue participating in sports with concussions unknowingly and be predisposed to prolonged recoveries.17,18
Concussions go unreported for numerous extrinsic (eg, pressure from teammates) and intrinsic (eg, not knowing the signs and symptoms of a concussion) factors.4,8,19 The extrinsic and intrinsic factors can vary between sport and sex due to psychosocial influencers and cultural ideologies, such as playing through pain.19 Specifically, females have been found to have better concussion reporting behavior than males in high school settings, but it is unknown whether differences are present at the collegiate level.20,21 Although numerous reasons for not reporting a concussion exist, insight into the role that knowledge plays on improving concussion reporting remains limited.
Improving concussion knowledge has been the focus of educational programs such as those mandated by the National Collegiate Athletic Association (NCAA),22 the Centers for Disease Control and Prevention's “Heads Up” initiative,23 and sport concussion laws across numerous states.24 NCAA collegiate student-athletes are recommended to be exposed to concussion education documents throughout each year of sport participation, theoretically improving their concussion knowledge and likelihood to report a potential injury. Despite required concussion education, there are mixed results of the effectiveness of educational interventions (ie, improving concussion knowledge) to increase concussion reporting, despite widespread implementation, with some studies demonstrating reporting improvement4,9 and others limited effect.25 Although higher concussion knowledge has been associated with greater reporting rates in high school student-athletes,9 no previous studies have investigated the interaction of knowledge on reporting intentions in collegiate student-athletes. To determine if improving knowledge is valuable for increasing concussion reporting, further examination is warranted.
The primary purpose of this study was to examine if concussion knowledge is a predictor of concussion reporting intentions in collegiate student-athletes. We hypothesized that concussion knowledge would be a significant predictor of reporting intentions. If concussion knowledge is an important predictor of concussion reporting intentions, a more thorough investigation of concussion knowledge differences between key demographic characteristics is necessary to best target groups needing education. Thus, the secondary purpose was to identify demographic differences based on sex, age, and years of sport eligibility in collegiate student-athletes. We hypothesized that older, female student-athletes who had fewer years of sport eligibility remaining would display greater concussion knowledge than their comparative groups.
Study Design and Participants
The current study had a cross-sectional design, used a convenience sample, and was part of a larger study that examined the effect of numerous psychosocial factors on concussion reporting in collegiate student-athletes. The larger study administered a survey monthly for 1 year. The current study describes three surveys administered during a 4-month period. Multiple online surveys were distributed to varsity collegiate student-athletes from three universities (Division I, Division II, and Division III) in the state of Georgia during a 12-month period by their respective sports medicine teams following consent to participate in the larger study. Across the three universities, 828 student-athletes were approached to participate.
Of the 828 student-athletes, 493 consented to receive the monthly online surveys, with 105 completing the surveys for the current study. The three universities were selected based on convenience and served as a sample of the three NCAA divisions. On completion of their annual NCAA-mandated concussion education and before the beginning of their respective athletic seasons, all student-athletes from the universities were included if they voluntarily provided their phone number for the monthly survey distribution and consented to participate in the study. To decrease attrition, student-athletes received a small monetary incentive if 80% or more of the monthly surveys were completed. Student-athletes were excluded if any of these three listed portions occurred: if they did not fully complete both concussion knowledge surveys, they did not complete the reporting intentions surveys, or if they experienced a concussion or “bell-ringer” in the month prior to each survey distribution. Clinical use of the term “bell-ringer” is discouraged because it downplays concussion severity, but it was used in the current study to capture student-athletes who likely or did sustain a concussion. No other inclusion or exclusion criteria were used. This study was approved by the University of Georgia's Institutional Review Board, and informed consent was obtained from all individual participants included in the study.
Instrumentation and Administration
Following consent to participate in the study, student-athletes were asked to answer demographic questions (Table 1). Years of eligibility remaining included the following options: 4 years (eg, incoming freshman prior to start of season), 3 years (eg, sophomore), 2 years (eg, junior), or 1 year (eg, senior). Three separate surveys in an online digital format were distributed for the current study. A single concussion reporting intentions survey26–28 and two concussion knowledge surveys (indirect knowledge agreement27–29 and direct knowledge assessment9) were administered individually over a 4-month period and were separated by at least 1 month. Surveys were spaced apart to not overwhelm student-athletes with numerous surveys in a short period of time, which in turn could decrease the response rate.
The indirect knowledge agreement and direct knowledge assessment surveys evaluated knowledge in different ways. The surveys were used to determine if one survey was a better predictor of concussion reporting intentions. One hundred five student-athletes completed both the direct knowledge assessment and concussion reporting intentions survey, with 77 of those student-athletes also completing the indirect knowledge agreement survey (Table 1). All surveys were administered through online survey software (Qualtrics Lab, Inc). Student-athletes received a web link to complete the survey on their computer or mobile device and were given at least 2 weeks to complete each survey.
Reporting Intentions Survey
The first survey assessed concussion and symptom reporting intentions and was formed by merging two previously validated surveys (Table 2).26,27 The survey was pilot tested among 64 student-athletes to ensure internal consistency and test–retest reliability following survey merging and was found to have fair to excellent reliability (alpha = 0.92, intraclass coefficient [ICC]2,1 = 0.52). The survey consisted of an 11-item questionnaire scored on a 7-point Likert scale with corresponding levels of agreement (eg, 1 = strongly disagree; 7 = strongly agree). Eight of the 11 items (items 1 to 8) assessed symptom reporting intentions by asking student-athletes if they would report a concussion based on the symptom stated. The remaining three items (items 9 to 11) assessed concussion reporting intentions by explicitly asking if the student-athletes intend, plan, or will make an effort to report a concussion when they experience signs or symptoms. All items were kept in their original format from the adopted surveys. Symptom and concussion reporting intentions were determined separately by calculating the average Likert score for each category.26,27
Concussion Reporting Intentions Survey Questionnaire and Responses
Indirect Knowledge Agreement Survey
The second valid and reliable survey27–29 examined overall concussion knowledge using 13-items (Table 3) scored on a 7-point Likert scale with corresponding levels of agreement. The indirect knowledge agreement survey was pilot tested and found to have fair reliability (alpha = 0.64, ICC2,1 = 0.62). All items asked the student-athletes to score their level of agreement (eg, 1 = strongly disagree; 7 = strongly agree) with each concussion-related item. Three of the 13 items (items 2, 4, and 12) were assessed but omitted from statistical analyses, due to the lack of a definitive, evidence-based correct answer to these statements (Table 3). The remaining 10 items were averaged to calculate a cumulative composite score for the indirect knowledge agreement survey.27
Indirect Knowledge Agreement Survey Items and Responses
Direct Knowledge Assessment Survey
The third survey was previously validated9 and included 42 total items, with 35 items assessing the student-athlete's concussion knowledge (Table 4). Of the 35 items, concussion knowledge was assessed through direct statements with definitive, correct responses for concussion signs and symptoms recognition (20 items) and general concussion knowledge (15 items). Signs and symptoms recognition asked the student-athlete to recognize whether the listed sign or symptom was associated with concussion. The general concussion knowledge section asked the student-athlete to select the correct true or false response for two items, multiple-choice response for 12 items, and open-ended response for one item. This survey was separated into two composite scores (signs and symptoms recognition and general knowledge) to differentiate between knowledge components. Signs and symptoms recognition composite scores were calculated by summing the number of correct signs and symptoms items and dividing by 20 (resulting in a percent correct score). General concussion knowledge composite scores were calculated by summing the remaining 15 questions and dividing by 15 (resulting in a percent correct score). Percent scores were calculated to allow for an easier interpretation of the statistical analysis.
Direct Knowledge Assessment Survey Items and Responses
Descriptive statistics and frequencies were calculated for student-athlete demographics, collegiate division level, and years of sport eligibility remaining. Survey item descriptive statistics were also calculated for each of the 20 signs and symptoms, 15 general knowledge, and 13 indirect knowledge agreement items.
For the primary purpose, two multiple linear regression analyses were performed using the enter method to examine the influence of the three concussion knowledge composite scores (predictor variables) on symptom and concussion reporting intentions (criterion variables). The multiple regressions were assessed for multicollinearity using the variance inflation factor, independence of observations using the Durbin-Watson statistic, significant outliers, and for residual errors appearing normally distributed.
For the secondary purpose, multiple one-way analyses of variance were used to compare differences in sex, years of sport eligibility, and age for the three concussion knowledge composite scores. The independent variables were sex (male or female), age (18, 19, 20, or 21 years or older), and years of sport eligibility remaining (2, 3, or 4 years). One year of sport eligibility remaining was not analyzed because no student-athletes with 1 year remaining completed the direct knowledge assessment and reporting intention survey. The dependent variables were signs and symptoms recognition, general knowledge, and indirect knowledge agreement composite scores. Post-hoc Tukey HSD comparisons were conducted if warranted. All statistical significance levels were set to alpha = 0.05 a priori and were conducted using SPSS software (version 22.214.171.124; IBM Corporation).
A total of 105 student-athletes (50 males, 55 females; age 19.2 ± 1.0 years; response rate 21.3%) completed the direct knowledge assessment and reporting intentions survey. Of those 105, 77 student-athletes (34 males, 43 females; age 19.2 ± 1.0 years) also completed the indirect knowledge agreement survey. Student-athlete descriptive and demographic data are presented in Table 1.
Collegiate Student-Athletes' Concussion Knowledge
Student-athletes had a mean score of 74.1% ± 12.9% (range: 45.0% to 95.0%; median = 75.0%) on signs and symptoms recognition and a mean score of 80.2% ± 8.7% (range: 60.0% to 93.3%; median = 80.0%; Table 4) on general knowledge. The combined direct knowledge assessment survey (signs and symptoms recognition and general knowledge) mean score was 77.9% ± 9.3% correct. The average indirect knowledge agreement score was 53.2 ± 6.3 (range: 31.0 to 69.0; median = 54.0) with individual item results presented in Table 3.
Knowledge as a Predictor of Concussion Reporting Intentions
The regression model (concussion signs and symptoms recognition, general knowledge, and indirect knowledge agreement) was not significant and accounted for only 6.9% of the symptom reporting intentions variability (R2 = .069, F3,73 = 1.81, P = .152). Neither signs and symptoms recognition (P = .861) nor general knowledge (P = .431) were significant predictors of symptom reporting intentions in the regression model, but indirect knowledge agreement was statistically significant (P = .024).
The regression model (concussion signs and symptoms recognition, general knowledge, and indirect knowledge agreement) significantly explained 12.9% of the concussion reporting intentions variability (R2 = 0.129, F3,73 = 3.61, P = .017). For every 1 Likert point increase in indirect knowledge agreement, there was a 0.66 increase in concussion reporting intentions (ß = 0.66, t73 = 3.25, P = .002). Signs and symptoms recognition (P = .937) and general knowledge (P = .242) were not significant predictors of concussion reporting intentions.
Age, Sex, and Years of Sport Eligibility Influence on Concussion Knowledge
Although females had better signs and symptoms recognition than males (females: 79.1% ± 12.3% vs males: 73.0% ± 13.5%; mean difference 95% confidence interval [CI]: 1.1% to 11.1%; F1,104 = 5.87, P = .017). However, sex did not significantly influence general or indirect knowledge agreement (P ≥ .117). Neither age (P ≥ .491) nor years of sport eligibility (P ≥ .393) significantly influenced any of the three concussion knowledge composite scores (Table 5).
Age, Sex, and Years of Eligibility Influence on Concussion Knowledge
We found that the indirect knowledge agreement survey best predicted concussion reporting intentions, and females possessed more concussion knowledge than males. In addition to these key findings, we also described the knowledge survey responses to understand collegiate student-athletes' comprehension of concussion.
Knowledge as a Predictor of Concussion Reporting Intentions
The indirect knowledge agreement survey significantly predicted concussion reporting intentions, whereas the direct knowledge assessment survey (comprising signs and symptoms recognition and general knowledge) did not. Both general knowledge and indirect knowledge agreement examined global concepts of concussion facts and the difference may relate to the relative difficulty of each survey's items. Anecdotally, items from the indirect knowledge agreement survey appear to address more advanced concepts such as: “Even if a player is experiencing the effects of a concussion, performance on the field of play will be the same as it would be had the player not experienced a concussion” or “People who have had a concussion are more likely to have another concussion.” It is plausible that the indirect knowledge agreement survey may have differentiated individuals with more basic concussion knowledge from those with more advanced knowledge. This may have led to our statistically significant findings for concussion reporting intentions using this survey; however, this is theoretical and we were unable to assess this.
Although the indirect knowledge agreement was statistically significant when predicting concussion reporting intentions, the three concussion knowledge composite scores only accounted for 12.9% of concussion reporting intentions, thus holding limited clinical value. Our results suggest that if a collegiate student-athlete were to increase two levels of agreement (eg, from neutral to agree) on the indirect knowledge agreement survey, concussion reporting intentions would theoretically increase by a mean of 1.32. This would result in a one level of agreement (eg, neutral to somewhat agree) concussion reporting intentions increase, although this assumes that a linear relationship exists between indirect knowledge and reporting intentions. However, getting student-athletes to improve reporting intentions may be challenging because student-athletes of all ages, sports, and competition levels are under the influence of other factors, such as external pressure from coaches and team-mates to not report.4,5,9,11,13
Based on the relationship between concussion knowledge and reporting intentions overall, the clinical utility of improving concussion knowledge is questionable. Concussion knowledge did statistically account for a portion of concussion reporting intentions, but, conversely, it did not explain 87.1% of concussion reporting intentions. This large percentage of unexplained variance suggests that concussion knowledge may be of value, but it only explains a small portion of why student-athletes intend to report. Our results are similar to those for high school student-athletes, indicating concussion knowledge is only one of many potential factors to consider improving to positively impact concussion reporting.9
The Theory of Planned Behavior,30 a psychosocial health behavior model, has been applied to sport concussion research to understand and examine why student-athletes do not report their concussions.26,27,31 To summarize the theory, intentions to perform a behavior are the most predictive variable for behavior (ie, intending to report a concussion is predictive of actually reporting) and intentions are predicted by an individual's attitude toward the behavior, subjective norms (ie, perceived social pressure to perform an action), and perceived behavioral control (ie, perceived capability to perform a behavior). Further understanding of how these factors contribute to concussion reporting and how they can be improved may help researchers and clinicians to increase concussion reporting. The Theory of Planned Behavior is directly related to other factors, such as the perception of concussion reporting in a student-athlete's social group, external pressure from coaches and teammates, and a student-athlete's willingness to play, all of which may better determine concussion reporting intentions.19,26,32,33 Clinicians should continue using concussion education programs but understand that concussion knowledge only accounts for a small portion of a student-athlete's multifactorial concussion reporting intention. Caution should be taken in relying solely on a student-athlete's concussion knowledge to meaningfully influence reporting.
Commonly occurring concussion signs and symptoms (eg, headache, dizziness, and nausea) were more correctly identified than uncommonly reported signs and symptoms (eg, amnesia or insomnia).34 Overall, 77% of collegiate student-athletes correctly identified loss of consciousness, despite its low prevalence following concussion.34,35 We observed slightly lower direct knowledge assessment scores (77.9% ± 9.3%) in our collegiate cohort than previous reports of high school student-athletes (79.7% ± 8.0%) using the same survey.9 This is interesting given the high school data were collected between 2008 and 2010, whereas our data were collected in 2017. Since 2008, there has been increased media coverage of concussion in sport, emphasis on concussion education, and adoption of concussion legislation policies in every state. We theorized that concussion knowledge would be higher in collegiate student-athletes, specifically older student-athletes, due to greater emphasis on and more years of concussion education exposure. However, high school and collegiate student-athletes, regardless of their age, performed similarly on signs and symptoms recognition.
The indirect knowledge agreement had an overall average score of 5.3, indicating an average response of “somewhat agree” to the survey items in Table 3. Indirect knowledge agreement responses possessed wide ranges for each item, but item modes were all either 6s (agree) or 7s (strongly agree), with the exception of survey items five and eight. Our results vary slightly from another study employing the same indirect knowledge agreement survey in college-aged ice hockey athletes.27 The mean score for each item's response from our current study indicated higher levels of knowledge than the previous study, with the exception of item two, which was excluded from analysis. These improvements may be due to our multisport sample and that the previous study's data were collected between 2012 and 2013.
Concussion knowledge may not be the sole factor for predicting reporting intentions. Our findings question the efficacy of concussion education programs that focus on knowledge transfer.4,25,36 Concussion education programs (such as those mandated by the NCAA22 and the “Heads Up” initiative23 launched by the Centers for Disease Control and Prevention) aim to teach all student-athletes the signs and symptoms, risks, and what to do for a suspected concussion. Although these education tools are considered valuable in concussion awareness and reporting, emerging evidence and our findings highlight that concussion knowledge may only play a small role in influencing concussion reporting intentions and/or behaviors.4,25,36
Demographic Differences in Concussion Knowledge
We hypothesized that older collegiate student-athletes having fewer years of sport eligibility remaining would possess greater concussion knowledge. These two variables were examined based on a pragmatic belief that older student-athletes were likely to have more concussion knowledge due to increased exposure to mandated collegiate education.22 Despite these assumptions, we did not observe any concussion knowledge differences based on age or years of sport eligibility remaining. These results may indicate that, after a certain amount of concussion education exposure, student-athletes reach a knowledge plateau and repetitive education exposure may have limited value.
Similar to previous studies,20,21 we report that females scored significantly better for concussion signs and symptoms recognition than males. Despite statistically significant differences between sexes, it is unclear if this finding has clinical meaning. Females scored approximately 6% better than males. This difference is equivalent to females correctly identifying one more sign or symptom recognition item than males, suggesting one group does not need intervention to correct the deficits. Although student-athletes display comparable knowledge scores to high school student-athletes, it is important to remember concussion reporting intentions were minimally influenced.
The surveys employed were administered at different time points 1 month apart from each other. It is possible that a student-athlete's concussion reporting intention could have changed over time due to uncontrollable education exposure (eg, hearing a signs and symptoms checklist being administered or reading a news article). However, surveys were distributed over a 3-month period and student-athletes diagnosed as having a concussion during this timeframe were excluded from the study. Although concussions diagnosed during the study timeframe were omitted, we did not control for any history of concussion in our analyses. Student-athletes also did not receive formal concussion education throughout the study. Additionally, our sample does not represent the entire spectrum of NCAA student-athletes or sports; therefore, the interpretation may not apply to certain groups (specifically football student-athletes) because our sample did not include any. Finally, we were not able to guarantee if student-athletes gave full effort while taking the online survey, but this limitation is inherent with most survey-based studies. Although effort cannot be fully controlled, we excluded student-athletes who did not completely answer each survey.
Implications for Clinical Practice
Based on our findings and previous studies, clinicians should understand that concussion knowledge is valuable and needed for student-athletes to have basic comprehension of concussions. However, clinicians should also be cautious of relying on improving concussion knowledge alone to influence a student-athlete's reporting intentions or behaviors. Clinicians should critically examine if a culture of honesty and support exists regarding injury reporting between the stakeholders and student-athletes in their clinical practice to ensure optimal safety and reduce the approximately 50% of unreported concussion.4–13 Future research should thoroughly investigate the potential to intervene on the student-athlete's psychosocial environment along with concussion knowledge to potentially improve concussion reporting intentions and behaviors.
The indirect knowledge agreement survey is a limited predictor of concussion reporting intentions. Small differences exist between sexes on concussion knowledge, but these differences may not be clinically meaningful. Overall, concussion knowledge plays a role, albeit minor, in influencing student-athletes' concussion reporting intentions. Concussion knowledge interventions focused solely on knowledge transfer likely provide minimal benefit but should still be used to ensure student-athletes possess basic knowledge and understand the risks of competing with a concussion.
- Wasserman EB, Kerr ZY, Zuckerman SL, Covassin T. Epidemiology of sports-related concussions in National Collegiate Athletic Association athletes from 2009–2010 to 2013–2014: symptom prevalence, symptom resolution time, and return-to-play time. Am J Sports Med. 2016;44:226–233. doi:10.1177/0363546515610537 [CrossRef]
- Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National high school athlete concussion rates from 2005–2006 to 2011–2012. Am J Sports Med. 2014;42:1710–1715. doi:10.1177/0363546514530091 [CrossRef]
- Zuckerman SL, Kerr ZY, Yengo-Kahn A, Wasserman E, Covassin T, Solomon GS. Epidemiology of sports-related concussion in NCAA athletes from 2009–2010 to 2013–2014: incidence, recurrence, and mechanisms. Am J Sports Med. 2015;43:2654–2662. doi:10.1177/0363546515599634 [CrossRef]
- Wallace J, Covassin T, Nogle S, Gould D, Kovan J. Knowledge of concussion and reporting behaviors in high school athletes with or without access to an athletic trainer. J Athl Train. 2017;52:228–235. doi:10.4085/1062-6050-52.1.07 [CrossRef]
- Delaney JS, Caron JG, Correa JA, Bloom GA. Why professional football players chose not to reveal their concussion symptoms during a practice or game. Clin J Sport Med. 2018;28:1–12. doi:10.1097/JSM.0000000000000495 [CrossRef]
- Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concussions among university football and soccer players. Clin J Sport Med. 2002;12:331–338. doi:10.1097/00042752-200211000-00003 [CrossRef]
- Echlin PS, Tator CH, Cusimano MD, et al. A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates. Neurosurg Focus. 2010;29:E4. Erratum in: Neurosurg Focus. 2010;29E5. doi:10.3171/2010.9.FOCUS10186 [CrossRef]
- 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;14:13–17. doi:10.1097/00042752-200401000-00003 [CrossRef]
- Register-Mihalik JK, Guskiewicz KM, McLeod TC, Linnan LA, Mueller FO, Marshall SW. Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. J Athl Train. 2013;48:645–653. doi:10.4085/1062-6050-48.3.20 [CrossRef]
- Broglio SP, Vagnozzi R, Sabin M, Signoretti S, Tavazzi B, Lazzarino G. Concussion occurrence and knowledge in Italian football (soccer). J Sports Sci Med. 2010;9:418–430.
- Kerr ZY, Register-Mihalik JK, Kroshus E, Baugh CM, Marshall SW. Motivations associated with non-disclosure of self-reported concussions in former collegiate athletes. Am J Sports Med. 2016;44:220–225. doi:10.1177/0363546515612082 [CrossRef]
- McDonald T, Burghart MA, Nazir N. Underreporting of concussions and concussion-like symptoms in female high school athletes. J Trauma Nurs. 2016;23:241–246. doi:10.1097/JTN.0000000000000227 [CrossRef]
- Fraas MR, Coughlan GF, Hart EC, McCarthy C. Concussion history and reporting rates in elite Irish rugby union players. Phys Ther Sport. 2014;15:136–142. doi:10.1016/j.ptsp.2013.08.002 [CrossRef]
- Broglio SP, Macciocchi SN, Ferrara MS. Sensitivity of the concussion assessment battery. Neurosurgery. 2007;60:1050–1057. doi:10.1227/01.NEU.0000255479.90999.C0 [CrossRef]
- Resch JE, Brown CN, Schmidt J, et al. The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one. BMJ Open Sport Exerc Med. 2016;2:e000012. doi:10.1136/bmjsem-2015-000012 [CrossRef]
- Garcia GP, Broglio SP, Lavieri MS, McCrea M, McAllister TCARE Consortium Investigators. Quantifying the value of multidimensional assessment models for acute concussion: an analysis of data from the NCAA-DoD Care Consortium. Sports Med. 2018;48:1739–1749. doi:10.1007/s40279-018-0880-x [CrossRef]
- Elbin RJ, Sufrinko A, Schatz P, et al. Removal from play after concussion and recovery time. Pediatrics. 2016;138:e20160910. doi:10.1542/peds.2016-0910 [CrossRef]
- 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 Train. 2016;51:329–335. doi:10.4085/1062-6050-51.5.02 [CrossRef]
- Kroshus E, Garnett B, Hawrilenko M, Baugh CM, Calzo JP. Concussion under-reporting and pressure from coaches, teammates, fans, and parents. Soc Sci Med. 2015;134:66–75. doi:10.1016/j.socscimed.2015.04.011 [CrossRef]
- Wallace J, Covassin T, Beidler E. Sex differences in high school athletes' knowledge of sport-related concussion symptoms and reporting behaviors. J Athl Train. 2017;52:682–688. doi:10.4085/1062-6050-52.3.06 [CrossRef]
- Kurowski B, Pomerantz WJ, Schaiper C, Gittelman MA. Factors that influence concussion knowledge and self-reported attitudes in high school athletes. J Trauma Acute Care Surg. 2014;77:S12–S17. doi:10.1097/TA.0000000000000316 [CrossRef]
- John T. Parsons. 2014–15 NCAA Sports Medicine Handbook. National Collegiate Athletic Association. http://www.ncaapublications.com/productdownloads/MD15.pdf. Published August 2014.
- Centers for Disease Control and Prevention. A Fact Sheet for High School Athletes. 2017. https://www.cdc.gov/headsup/pdfs/high-schoolsports/athletes_fact_sheet-a.pdf. Accessed January 29, 2018.
- National Conference of State Legislatures. Traumatic Brain Injury Legislation. http://www.ncsl.org/research/health/traumatic-brain-injury-legislation.aspx. Published October 11, 2018. Accessed December 14, 2018.
- Kroshus E, Baugh CM, Hawrilenko MJ, Daneshvar DH. Determinants of coach communication about concussion safety in US collegiate sport. Ann Behav Med. 2015;49:532–541. doi:10.1007/s12160-014-9683-y [CrossRef]
- 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 Inj. 2013;27:878–886. doi:10.3109/02699052.2013.775508 [CrossRef]
- Kroshus E, Baugh CM, Daneshvar DH, Viswanath K. Understanding concussion reporting using a model based on the theory of planned behavior. J Adolesc Health. 2014;54:269–274.e2. doi:10.1016/j.jadohealth.2013.11.011 [CrossRef]
- Kroshus E, Baugh CM, Hawrilenko M, Daneshvar DH. Pilot randomized evaluation of publically available concussion education materials: evidence of a possible negative effect. Health Educ Behav. 2015;42:153–162. doi:10.1177/1090198114543011 [CrossRef]
- Rosenbaum AM, Arnett PA. The development of a survey to examine knowledge about and attitudes toward concussion in high-school students. J Clin Exp Neuropsychol. 2010;32:44–55. doi:10.1080/13803390902806535 [CrossRef]
- Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211. doi:10.1016/0749-5978(91)90020-T [CrossRef]
- Rigby J, Vela L, Housman J. Understanding athletic trainers' beliefs toward a multifacted sport-related concussion approach: application of the theory of planned behavior. J Athl Train. 2013;48:636–644. doi:10.4085/1062-6050-48.3.10 [CrossRef]
- Kroshus E, Baugh CM, Stein CJ, Austin SB, Calzo JP. Concussion reporting, sex, and conformity to traditional gender norms in young adults. J Adolesc. 2017;54:110–119. doi:10.1016/j.adolescence.2016.11.002 [CrossRef]
- Martin RK, Hrubeniuk TJ, Witiw CD, MacDonald P, Leiter J. Concussions in community-level rugby: risk, knowledge, and attitudes. Sports Health. 2017;9:312–317. doi:10.1177/1941738117695777 [CrossRef]
- O'Connor KL, Baker MM, Dalton SL, Dompier TP, Broglio SP, Kerr ZY. Epidemiology of sport-related concussions in high school athletes: National Athletic Treatment, Injury and Outcomes Network (NATION), 2011–2012 through 2013–2014. J Athl Train. 2017;52:175–185. doi:10.4085/1062-6050-52.1.15 [CrossRef]
- Kerr ZY, Zuckerman SL, Wasserman EB, Covassin T, Djoko A, Dompier TP. Concussion symptoms and return to play time in youth, high school, and college american football athletes. JAMA Pediatr. 2016;170:647–653. doi:10.1001/jamapediatrics.2016.0073 [CrossRef]
- Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2014;48:135–140. doi:10.1136/bjsports-2013-092498 [CrossRef]
|Characteristic||Direct Knowledge (n = 105)a||Indirect Knowledge (n = 77)b|
| 21 to 22||11||10.5||10||12.9|
| Division I||38||36.2||26||33.8|
| Division II||17||16.2||14||18.2|
| Division III||50||47.6||37||48.0|
|Years of sport eligibility remaining|
Concussion Reporting Intentions Survey Questionnaire and Responses
|Reporting Intentionsa,b||Mean ± SD||Mode||Range|
| 1. See stars||6 ± 1.6||7||1 to 7|
| 2. Vomit or feel nauseous||6 ± 1.6||7||1 to 7|
| 3. Have a hard time remembering things||6 ± 1.5||7||1 to 7|
| 4. Have problems concentrating on the task at hand||5 ± 1.8||7||1 to 7|
| 5. Feel sensitive to light or noise||6 ± 1.7||7||1 to 7|
| 6. Have a headache||5 ± 1.9||5||1 to 7|
| 7. Experience dizziness or balance problems||6 ± 1.6||7||1 to 7|
| 8. Feel sleepy or in a fog||5 ± 1.9||7||1 to 7|
| 9. I intend to report||6 ± 1.2||7||1 to 7|
| 10. I plan to report||6 ± 1.2||7||1 to 7|
| 11. I will make an effort to report||6 ± 1.2||7||1 to 7|
Indirect Knowledge Agreement Survey Items and Responses
|Statementa||Mean ± SD||Mode||Range|
|1. People who have had a concussion are more likely to have another concussion.||5.2 ± 1.5||6||1 to 7|
|2. There is a possible risk of death if a second concussion occurs before the first one has healed.b||5.2 ± 1.2||5||1 to 7|
|3. A concussion cannot cause brain damage unless the person has been knocked out.c||6.1 ± 1.2||7||1 to 7|
|4. The brain never fully heals after a concussion.b||4.2 ± 1.4||5||1 to 7|
|5. It is easy to tell if a person has a concussion by the way the person looks or acts.c||4.4 ± 1.5||3||1 to 7|
|6. Symptoms of a concussion can last for several weeks.||6.0 ± 1.2||6||1 to 7|
|7. Resting your brain by avoiding things such as playing video games, texting, and doing schoolwork is important for concussion recovery.||6.1 ± 1.3||7||2 to 7|
|8. After a concussion occurs, brain imaging (eg, computer assisted tomography scan, magnetic resonance imaging, x-ray, etc.) typically shows visible physical damage to the brain (eg, bruise, blood, or clot).c||3.3 ± 1.3||4||2 to 7|
|9. A concussion may cause an athlete to feel depressed or sad.||5.9 ± 1.5||6||2 to 7|
|10. Once an athlete feels “back to normal,” the recovery process is complete.c||5.3 ± 1.4||6||2 to 7|
|11. Even if a player is experiencing the effects of a concussion, performance on the field of play will be the same as it would be had the player not experienced a concussion.c||5.7 ± 1.4||7||1 to 7|
|12. Concussions pose a risk to an athlete's long-term health and well-being.b||6.1 ± 1.1||6||1 to 7|
|13. A concussion can only occur if there is a direct hit to the head.c||5.1 ± 1.5||6||1 to 7|
Direct Knowledge Assessment Survey Items and Responses
|Survey Items (Correct Response)||Frequency of Correct Responses (%)|
|Signs and symptoms recognitiona|
| Skin rash (false)||103 (98.1)|
| Bleeding from the mouth (false)||97 (92.4)|
| Fever (false)||97 (92.4)|
| Black eye (false)||96 (91.4)|
| Joint stiffness (false)||92 (87.6)|
| Abnormal sense of smell (false)||87 (82.9)|
| Blurred vision (true)||85 (81.0)|
| Bleeding from the nose (false)||85 (81.0)|
| Dizziness (true)||84 (80.0)|
| Headache (true)||83 (79.0)|
| Bleeding from the ear (false)||81 (77.1)|
| Loss of consciousness (true)||81 (77.1)|
| Abnormal sense of taste (false)||80 (76.2)|
| Confusion (true)||79 (75.2)|
| Nausea (true)||74 (70.5)|
| Numbness or tingling of arms (false)||74 (70.5)|
| Sharp burning pain in neck (false)||72 (68.6)|
| Weakness in neck movements (false)||57 (54.3)|
| Amnesia (true)||51 (48.6)|
| Insomnia (true)||42 (40.0)|
| A concussion occurs only if you lose consciousness. (false)||103 (98.1)|
| If you are experiencing any signs and symptoms of concussion after a blow to the head or sudden movement of the body, you should not return to play. (true)||98 (93.3)|
| A concussion is an injury to the ___________. (fill in the blank) (brain)||60 (57.1)|
| I don't know (false/not selected)||105 (100.0)|
| No complications exist (false)||104 (99.0)|
| Brain damage (true)||104 (99.0)|
| Memory problems (true)||102 (97.1)|
| Increased risk of further injury (true)||93 (88.6)|
| Joint problems (false)||80 (76.2)|
Age, Sex, and Years of Eligibility Influence on Concussion Knowledge
|Characteristic||Indirect Knowledge Agreement||Signs and Symptoms Recognition||General Knowledge|
|Mean ± SD||P||Mean ± SD||P||Mean ± SD||P|
| Male||5.3 ± 0.7||.757||73.0 ± 13.5||.017a||78.8 ± 8.4||.117|
| Female||5.3 ± 0.6||79.1 ± 12.3||81.5 ± 8.8|
| 18||5.3 ± 0.7||.426||73.6 ± 12.5||.464||80.5 ± 8.7||.517|
| 19||5.2 ± 0.5||77.2 ± 12.7||78.5 ± 9.3|
| 20||5.5 ± 0.7||78.5 ± 13.2||81.6 ± 7.9|
| ≥ 21||5.2 ± 0.5||73.6 ± 16.5||81.2 ± 8.3|
|Years of sport eligibility remaining|
| 4||5.3 ± 0.7||.584||77.0 ± 11.6||.889||80.4 ± 8.3||.393|
| 3||5.3 ± 0.4||76.3 ± 14.1||78.7 ± 9.8|
| 2||5.4 ± 0.7||75.4 ± 13.9||81.5 ± 7.7|