In the media today, concussions are becoming a popular topic in regards to collegiate and professional athletics. There are an “estimated 300,000 sport-related traumatic brain injuries, predominantly concussions, occur annually in the United States” (Gessel, Fields, Collins, Dick & Comstock, 2007, p. 495). A concussion is “a form of traumatic brain injury that has been defined as a ‘trauma-induced alteration in mental status that may or may not involve loss of consciousness’” (Baugh, Kroshus, Daneshvar, & Stern, 2014, p. 314). In the past, a concussion was only diagnosed if the athlete lost consciousness, however as more research surfaced, concussions could happen with or without the loss of consciousness. Compared to other injuries, clinicians have to rely on the subjective information the athletes provide them. With an injury that is subjective and removes them from play, athletes have a possibility of hiding or not reporting the symptoms they experience.
The first question that could arise is what the symptoms of a concussion are. The possible symptoms of a concussion can include headache, nausea, dizziness, vision problems, light sensitivity, noise sensitivity, trouble focusing, memory problems, and heightened emotions (Davies & Bird, 2015). Every athlete that suffers from a concussion can experience a variety of the symptoms and the severity of the symptoms can vary as well. One concussion may present itself in a different way than another one. One of the ways to grade these subjective pieces of information is to rank them on a numerical scale for severity. For example, having athletes rate their pain or headache on a scale from zero to ten, with zero being none at all and ten being a “take to the emergency room intensity.” This is not only just a way to put objectivity on subjective data, but can be used to determine if the athlete’s recovery is progressing. Educating the athletes on what the symptoms of concussions are can be useful because “many athletes believe that ‘bell ringers’ or ‘dings’ are not concussions; rather, they are simply a part of the game and therefore are not reported” (Llewellyn, Burdette, Joyner, & Buckley, 2014, p. 76). Coaches may describe them as part of them because when the coaches participated, they may have been in the era of a concussion only occurs if there is a loss of consciousness. Updating the athletes with the current research can help them understand that what once was considered part of the game could actually be a serious injury.
Once athletes are provided with the education on what a concussion is and the symptoms, the reporting of a concussion can often fall on them to tell an athletic trainer, coach, doctor, or another individual. Athletes may self-report a concussion because they are educated on the consequences they could face if they continue to participate in their sport and want to avoid having to experience it. However, the athletes are faced with more factors to not report a concussion. According to a study performed by J. Scott Delaney and his colleagues, the most popular reasons the athletes surveyed decided to not report were that the athlete did not want to be removed from the game, felt like he or she was disappointing the team, felt that he or she would not be able to participate in the future, and that he or she could continue to play through it (Delaney, Lamfookon, Bloom, Al-Kashmiri, & Correra, 2015). Athletes may not report symptoms because they do not want to jeopardize their “roster spot.” Being unable to participate in a game due to injury might allow another athlete on the team a chance to shine and athletes may fear that when they return to play, they could potentially be a back up to their replacement. Understanding the reasons why an athlete may or may not report a concussion can influence the athletic trainer or medical professional to pay close attention to the athletes to determine when they may experience concussive symptoms.
Sex differences among athletes may play a role in whether the athlete reports a concussion. In a study performed by Dana Brown and her colleagues, they found “females [were] 43% more likely than males to report any symptom associated with concussion” (Brown, Elsass, Miller, Reed, & Reneker, 2015, p. 1027). One of the reasons why this may be occurring is females experience some of the same symptoms of concussions when they are in certain phases of their menstrual cycle; these symptoms could include “headache, difficulty concentrating, emotional symptoms, and energy/sleep disturbances” (Brown et al, 2015, p. 1027). For an athletic trainer or medical professional, it may be beneficial to ask a female athlete who has reported these symptoms where the athlete is in their menstrual cycle as well as knowing the mechanism of their injury. This could potentially affect the athlete during the return to play process as they could have an increase in symptom scores, even though the concussion might not be the cause for the increase.
Furthermore, athletes may experience pressure from significant people in their lives. The pressure from these individuals may be that the athlete needs to return to play or removing them from the activity. Some of these significant individuals may be coaches, teammates, or parents. In a study completed by Emily Kroshus and her colleagues, their results found “around one in four athletes experienced pressure from a teammate, coach or parent to continue play after a head impact, with no significant differences between male and female athletes” (Kroshus, Garnett, Hawrilenko, Baugh, & Calzo, 2015, p. 71).
Another difference in whether athletes report concussions is the sport that the athletes participate in. In some sports, such as football or hockey, concussions are thought to a part of the game. In a study done by Emily Kroshus and her colleagues, they surveyed male collegiate ice hockey players and asked questions about the athletes’ perceived reporting norms for themselves as well as other athletes. They found that “on average, respondents indicated that they themselves had safer reporting attitudes than what they perceived to be the reporting norms for ‘most athletes.’ Because the norm measure referred to ‘most athletes’ rather than ‘my teammates’ or ‘other male college hockey players’” (Kroshus, Kubzansky, Goldman & Austin, 2015, p. 100). Kroshus and her colleagues potentially thought that this could have been caused by a phenomenon called pluralistic ignorance, “where although individuals themselves reject a certain norm, they incorrectly assume that others subscribe to it” (2015, p. 100). This phenomenon could potentially skew the results. Team norms may need to be adjusted in order to have correct data about reporting rates among the athletes.
An interview completed by Matthew Moreau and his colleagues with four NCAA Division I student-athletes that experienced concussions gave insight to what the athletes may experience. One of the interviewees stated that she would go into the athletic training room and rate her symptoms on a numerical scale. She provided information that is useful to the athletic trainer or medical professional; she said that:
[She] was giving honest answers thinking if [she] was just getting better than [she] would be able to practice – not knowing that everything had to be a zero before [she] could practice … and it is probably good that they did not tell [her] because [she] probably would have just been like, ‘zero, zero, zero,’ all the way down. (Moreau, Langdon, & Buckley, 2014, p. 67)
It is important to educate athletes on concussions; however, the athletes could possibly become overeducated with the return to play policies that they may not always be truthful in their answers. Potentially educating the athlete on the need to have all zeros for their symptoms could cause athletes to lie or underestimate their symptoms and the severity. By not telling the athlete that they need to have all zeros in order to participate could allow the athlete to give truthful results of whether their concussion symptoms are diminishing or not.
Knowing the consequences that could happen if a concussion goes unreported could potentially increase the reporting rates among athletes. In a study performed by Breton Asken and his colleagues, they identified that:
Athletes who were not immediately removed from activity would ultimately have a lengthier recovery and miss more days of athletic activity compared with those who were immediately removed and evaluated by medical personnel. Delayed reporting of concussion symptoms was associated with a recovery time almost five days longer than that of athletes who immediately reported symptoms. (Asken, McCrea, Clugston, Snyder, Houck & Bauer, 2016, p. 332)
Educating the athletes to immediately report their symptoms could potentially return them to play quicker than if the athlete tries to play through the concussion. A factor that causes athletes to not report concussions are that they do not want to miss future competitions, however, managing a concussion immediately after it occurs could allow them to not miss as many than if they had to be pulled a later point because the concussion became too severe or the athlete experiences multiple impacts. Other potential consequences that could arise could be the long-term effects that an athlete may experience by underreporting concussions. Some of the long-term deficits could include “cognitive dysfunction, depression, and executive dysfunction … [and concussions] have been linked to neurodegenerative diseases, including chronic traumatic encephalopathy (CTE)” (Baugh, Kroshus, Bourlas & Perry, 2014, p. 297). CTE is:
A gradually progressing disease of the brain that occurs most frequently in athletes who have experienced repeated blows, including concussions, to the head … [the] repetitive brain trauma sparks a progressive degeneration of brain tissue and an excessive build-up of a protein called tau that can occur over months, years, or even decades … [It can lead] to potential memory loss, confusion, depression, aggression, impaired judgment, problems with impulse control, and dementia. (Miller, 2016)
Educating the athletes during the pre season is one of the most important things an athletic trainer or medical professional could do in order to ensure the athletes know the information about concussions. The most difficult thing is whether the athletes will utilize the information they were taught to report symptoms during the in-season. One way to do this during the pre season is to utilize educational programming, which “could provide athletes with opportunities to simulate making safe decisions in situations that aim to simulate ‘real life’” (Kroshus, Baugh, Daneshvar, Nowinski & Cantu, 2015, p. 245). Instead of having a lecture, allowing the athletes to role-play situations they or their teammates could potentially be in creates a better realization that concussions could impact them. Having an educational meeting about concussions before the sport season begins with all the athletes participating can increase their knowledge on concussions and it could “lead to an increase in injury reporting and appropriate management of concussive injuries” (Miyashita, Timpson, Frye & Gloeckner, 2013, p. 353). Presenting this information during the pre season allows the information to be fresh in the athletes’ minds for the in-season and can be a reminder of information that they heard the year before. Providing the information again helps athletes to not forget that experiencing a concussion is still a possibility in their sport.
Athletes may have a basic foundation of knowledge about concussions from their years of participating in athletics. Educating the athletes on in depth information may help prevent the underreporting of concussions because the athletes simply could have not known that was a potential symptom. Athletes could “readily highlight cognitive and somatic disturbances; however, psychiatric problems, such as changes in mood, irritability, anxiety, and depression are rarely mentioned” (Meier, Brummel, Singh, Nerio, Polanski & Bellgowan, 2015, p. 510). Since athletes may experience different symptoms and concussions could present themselves differently, athletes also need to know that the psychiatric symptoms may potentially occur.
Increasing education for the athletes participating in athletics is just as beneficial as increasing concussion education for the other personnel involved, such as coaches. In all the states in the United States, there is legislation about who needs to be educated about concussions and what the guidelines may consist of as well as for the student athletes (LaRoche, Nelson, Connelly, Walter, & McCrea, 2016). Coaches may not know the symptoms of concussion, or even that concussions do not always result in a loss of consciousness. The legislation “requires that an athlete be removed from play if a coach, official, or health care provider suspects a concussion or if an athlete exhibits signs of a concussion” (LaRoche, Nelson, Connelly, Walter, & McCrea, 2016, p. 34). Providing education to the coaches can be beneficial in order for them to recognize when an athlete may have suffered a concussion. Presenting the up-to-date information to the coaches with the consequences of not reporting concussions can show that there are long-term effects that the athlete could potentially face for the rest of their life that is not worth putting the athlete in danger in order to win the game. Communicating the information about the state’s legislation regarding concussions to the athletes as well as coaches may influence them to be more likely to report concussions.
Overall, increasing education about concussions not only benefits the athletes to know when to report concussions, but providing the education about concussions complies with the concussion policy of the National Collegiate Athletic Association’s (NCAA). For the NCAA’s concussion policy, it “requires that athletes acknowledge receipt of information about concussions and their responsibility to report concussion signs and symptoms to medical staff” (Baugh, Kroshus, Daneshvar, Filali, Hiscox, & Glantz, 2015, p. 54). Without educating the athletes on concussions, the school is violating the NCAA policy, which is in place to help protect the student-athletes. Being compliant could increase the probability of athletes reporting their symptoms because the staff can make the policy just as important as any of the other NCAA rules and policies that the college athletic teams have to follow.
Providing the athletes with information about concussions and the symptoms during the beginning of the season could potentially increase the reporting rates. With concussions being a highly subjective injury, the athletic trainer and other medical professionals have to rely on the information the athletes present. From that, the athletes could potentially not report their symptoms at all due to many factors, such as not wanting to be removed from the game to feeling like they disappointed their teammates. Athletes should be educated on the risks of not reporting concussions immediately after experiencing one; the athletic trainer and other medical personnel have to understand the factors that play a role in whether the athlete reports symptoms. There was very little research about what factors there are in regards to athletes reporting of teammates experiencing symptoms, however, educating the athletes more on what concussions are could potentially increase the rates of athletes reporting concussions of their teammates.