Overcoming The Culture Of Resistance To Concussion Symptom Reporting Will Take A Team Effort

In the sixteen years I have been writing about and reporting on sports-related concussions, there have been enormous scientific advances in our understanding of the injury, in how it is managed and treated, in its risk factors, and in its effects, both short- and long-term. When we launched MomsTEAM’s pioneering Concussion Safety Center in 2001, very few outside a small group of doctors knew much of anything about concussions, and some of what they thought they knew turned out to be wrong. Today, athletes, coaches, parents, athletic trainers, and doctors all know a great deal more, although it is safe to say that the more we know, the more we don’t know.

But despite increased education of athletes about concussion signs and symptoms, about the risks to their health in the short-, intermediate- and long-term from concussions, and from continuing to play with an undiagnosed concussion, one thing which has stubbornly resisted change is the rate at which athletes report concussions. The needle has barely moved: a 2004 study (1) reported that 40 to 60 percent of athletes did not report their concussions. The number is pretty much the same today. (2)

No wonder the Institutes of Health’s report on sports-related concussions (3) concluded in 2013 that sports at all levels continue to be characterized by what it famously dubbed a “culture of resistance” to concussion symptom reporting. The reason, anecdotal evidence and a number of recent studies suggest, is that student-athletes often experience pressure from coaches, peers, and parents to play hurt (4), and are taught that winning at the risk of their own health is not only acceptable but expected. It is hard to believe, given what we know – and don’t know – about the dangers of concussions (and of the cumulative effect of repetitive head impacts) – that athletes today still fear what may happen to them if they do not abide by what they perceive to be team and cultural norms by honestly self-reporting concussion symptoms.

MomsTEAM has been consistently advocating since at least 2004 that the best way to get athletes to honestly self-report experiencing concussion symptoms is for coaches to create an environment in which athletes feel safe in reporting.

As a result, I wasn’t the least bit surprised to read study after study over the last three or four years supporting our view and reporting that it is not so much an athlete’s knowledge about concussions that affects reporting behavior, as it is their attitudes and beliefs, and those of their key influencers (coaches, parents, teammates, and even fans) which are most responsible for the chronic under-reporting of concussion symptoms by athletes at all levels of sports. (5-10)

That research shows that:

beliefs by athletes about what they think will happen if they report a concussion, how important those are outcomes to them, what their teammates, coach, and parents think about their behavior, and how reporting impacts team performance, are all significantly associated with concussion reporting attitudes and behavior (6,8, 9, 11);
a team’s concussion reporting norms are an important predictor of whether an athlete chooses to report symptoms of potential concussions to medical personnel (12);
fully three-quarters of athletes in one recent study perceived their own reporting attitudes to be safer than those of their teammates (12):
misperceived or negative concussion reporting norms tend to persist because athletes who believe their preferences for honest concussion reporting are different from the team norms are less likely than athletes who believe their preferences conform to the team norm to express those preferences for fear of social disapproval, a self-perpetuating process that has been termed the ‘spiral of silence’ (12);
athletes who are aware of the adverse health and performance consequences of continuing to play while symptomatic for concussion, and who believe that being a good teammate means, if you suspect a teammate may have sustained a concussion (or even taken an especially hard hit), you should say something – to the teammate, the coach, or medical personnel, even a parent, to make sure the teammate is checked out medically on the sports sideline – are more likely to engage in such help-seeking behavior (12); and
an educational intervention designed to increase rates of concussion reporting solely by encouraging deliberative, rational behavior by the injured athlete is not likely enough, because athletes who sustain a concussion do not always act rationally (after all, concussion often renders them unable to think clearly and remember things, including the symptoms of concussion).

#TeamUp4ConcussionSafety

Building on the pioneering research of Emily Kroshus, Christine Baugh, Johna Register-Mihalik, Sarah Chrisman, and Tamara Valovich McLeod, and with funding from a NCAA-Department of Defense Mind Matters grant, SmartTeams™ has developed a pilot concussion education program called #TeamUp4ConcussionSafety which takes a new approach to tackling the problem of chronic under-reporting of concussion symptoms by focusing on changing attitudes, expectations, and behaviors of athletes and their key influencers (coaches, athletic trainers, and parents) through a multi-media educational intervention designed to:

correct any misperceptions by athletes that they have safer attitudes about concussion reporting than their teammates, coaches, and/or parents,
change any negative attitudes coaches, parents, and coaches may have towards concussion reporting;
engage coaches, players, parents, and medical personnel in a collaborative effort to set safe team norms and expectations about concussion reporting;
instill in coaches and athletes a shared understanding and belief that one of the most important responsibilities of being a member of a team is looking out for your own health and safety and that of your team members, both by immediately reporting concussion symptoms, encouraging teammates to report, and by telling someone if you observe a teammate exhibiting signs of concussion, even if they won’t;
emphasize that immediate symptom reporting and winning are not mutually exclusive: not only is reporting in the best interests of the athlete, because it reduces the risk of further injury and a longer recovery , but of the team as well, because an athlete who continues to play with concussion symptoms can hurt the team’s overall performance, and, by missing more games as a result of the concussion, hurting its chances of performing at its best in future games;
reduce actual or perceived pressure by coaches, parents, and teammates on athletes to continue playing with an undiagnosed concussion; and
create a climate in which athletes feel safe in reporting their symptoms, and encouraging their teammates to do the same.

Paradigm shift

I am not so naïve as to think that concussion symptom reporting, as a result of our new program, is going increase dramatically overnight, or over one season. After all, what we are trying to accomplish is nothing less than changing the very culture of sports when it comes to concussion, from one of resistance to injury reporting to one of safety.

In the short-term, however, we hope that athletes will learn that (1) not only are there negative health (13-15) and athletic performance consequences of continued play with concussion (16), but the team’s performance also is likely to suffer in the short-, intermediate- and long-term (16); (2) as a result, it is their responsibility as a member of a team, and the sign of a good teammate, to honestly self-report to the coach and/or medical staff whenever they are experiencing concussion symptoms, and, if they suspect that the teammate may have sustained a concussion, encouraging the injured teammate to seek medical help, or reporting the teammate to the medical staff if they don’t self-report; and that (3) concussion symptom reporting should therefore be a valued team behavior.

We hope that coaches will learn that (1) not only are there negative health and/or athletic performance consequences to their players from continuing to play with concussion, but their team’s performance will also likely suffer over the short-, intermediate- and long-term; (2) conservative concussion safety practices can be implemented without negative consequences to the team’s won-and-loss record or the coach’s personal goals; (3) their attitudes and beliefs about concussion safety greatly influence a team’s culture of safety; and (4) by expressly and consistently communicating to players positive concussion reporting expectations prior to the beginning of the pre-season, again before the season starts, at discrete intervals during the season; by consistently reinforcing safety-oriented behaviors (specifically, not continuing to play with concussion symptoms, players encouraging teammates to seek medical help in case of suspected concussion, and following the return-to-play protocol after concussion); by informing players that, if they sustain a concussion, they and their teammates will provide them with emotional and social support during the recovery process; and by maintaining a continuing and open dialog about concussion safety with their team, they can increase the likelihood that players will engage in positive concussion reporting behaviors.

In the intermediate-term, we believe that the percentage of athletes honestly self-reporting experiencing concussion symptoms will begin to increase.

In the long-term, we believe that the SmartTeams™ concussion safety program will help to create a culture of safety in which (1) athletes routinely inform medical personnel, coaches, and/or parents whenever they experience possible symptoms of concussion; (2) athletes routinely encourage teammates they suspect may have suffered concussions to seek medical help; (3) athletes routinely seek help for injured teammates if they do not self-report; (4) coaches, teammates, parents, and fans do not pressure athletes to continue playing with undiagnosed concussions; (5) fewer athletes sustain multiple concussions, experience extended recovery from concussion, or are forced to retire from sport because of their concussion history; and (6) short-, medium- and long-term adverse health consequences athletes in contact and collision sports suffer from continuing to play with undiagnosed concussions are significantly reduced, resulting in a significant benefit to society by reducing direct and indirect healthcare costs.

The only way any of this is going to happen, of course, is if all stakeholders are committed to working together as a team to create a culture of concussion safety. Unless they are, unless they pledge themselves to working, day in and day out, season after season, to creating an environment in which athletes feel safe and comfortable in reporting their symptoms, I’ll be reporting again ten years from now that 40 to 60% of athletes are still hiding their symptoms. I would much prefer to be able to report by then that chronic under-reporting has become a thing of the past.

1. 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(1):13-17.

2. Delaney JS, Lamfookon C, Bloom GA, Al-Kashmiri A, Correa JA. Why university athletes choose not to reveal their concussion symptoms during a practice or game. Clin J Sport Med. 2015;25(2):113-125.

3. Institute of Medicine (IOM) and National Research Council (NRC). 2013. Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press.

4. Kroshus E, Garnett B, Hawrilenko M, Baugh CM. Concussion under-reporting and pressure from coaches, teammates, fans, and parents. Social Sci & Med. 2015;134:66-75.

5. 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)

6. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.

7. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)

8. 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)

9. 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 Injury 2013;27(7-8):878-886.

10. Kroshus E, Baugh CM, Daneshvar DH, Nowinski CJ, Cantu RC. Concussion Reporting Intention: A Valuable Metric for Predicting Reporting Behavior and Evaluating Concussion Education. Clin J Sport Med. 2014; Post Author Corrections: July 21, 2014 doi: 10.1097/JSM.0000000000000137.

11. Kroshus E, Baugh CM, Daneshvar DH, et al. Understanding concussion reporting using a model based on the theory of planned behavior. J Adolesc Health 2014;54:269-274.

12. Kroshus E, Garnett BR, Baugh CM, Calzo JP. Social norms theory and concussion education. Health Ed. Research 2015;30(6):1004-1013.

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15. Vagnozzi R, Signoretti S, Tavazzi B, et al. Temporal window of metabolic brain vulnerability to concussion: a pilot IH-magnetic resonance spectroscope study in concussed athletes – part III. Neurosurgery 2008;62(6):1286-1296.

16. 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 Ath Tr. 2016;51(5):000-000. doi: 10.4085/1062-6050-51.5.02 (published online ahead of print)