Pillar One: Comprehensive Concussion Education

 

A comprehensive concussion risk management program begins with education.

When MomsTEAM, working with one of the country’s pre-eminent concussion experts, Dr. Robert Cantu, launched its comprehensive concussion center in 2001 – becoming, in Dr. Cantu’s words, the “pioneers” in youth sports concussion education – the subject was years away from gaining the attention of the national media.

Today, experts unanimously agree that concussion education should be at the top of the list of ways in which football – and all contact and collision sports – can be made safer.

All athletes, referees, administrators, parents, coaches, and health care providers involved in a contact or collision sport such as football should be educated about:

• ways to reduce the risk of concussion and brain/neck/spine injury and limit the number of repetitive head impacts, which a growing body of scientific evidence suggests may lead to more long-term cognitive problems than concussions (Pillar Two)
• the critical importance of early identification of concussion after one occurs, including the need to create an environment which encourages athletes to report their concussion symptoms and those of their teammates, and having an certified athletic trainer or other medical professional on the sideline to conduct an immediate concussion assessment (Pillar Three and #TeamUp4ConcussionSafety program)
• conservative treatment and management (physical and cognitive rest) and return to learn (Pillar Four)
• principles of cautious return to play, including completion of a symptom-limited exercise protocol (Pillar Five ); and
• factors suggesting that retirement from football and other contact and collision sports is advisable (Pillar Six)

Parents and Players

While every state in the country now requires that parents and players receive some basic concussion safety information as a condition to participation, much more education is needed.

Steps 1, 2, and 3 of SmartTeams™ #TeamUp4ConcussionSafety program, call for all parents and players to test their concussion knowledge and attitudes, fill in any knowledge gaps by taking an online concussion education course,  and attend a concussion safety meeting before every season focused on changing attitudes about concussion symptom reporting by emphasizing the performance benefits of honest symptom reporting to the athlete and their team, and creating a climate in which athletes feel comfortable in immediately reporting concussion symptoms.

Parents should learn:

1. to recognize the signs and symptoms of concussion:

2.to watch for delayed symptoms. It is not uncommon for concussion symptoms or signs, including behavioral changes, and concentration and memory problems, to only appear hours or even days after a strong blow to the body or head during practice or game action. Delayed symptom onset is especially common among younger athletes (1); 

3. the need to regularly and close monitor athletes during the first 24-48 hours after diagnosed concussion for signs of deteriorating mental condition suggesting a more serious brain injury which requires immediate hospitalization,

4. the benefits of  cognitive and physical rest in the first few days after concussion, including staying home from school, and the importance of a gradual return to school (Pillar Four) and to sports (Pillar Five); and

5. the dangers of continuing to play with concussion symptoms and/or returning to play too soon, before a child or teen’s still-developing brain has fully healed (Pillars Four and Five), including increased risk of potential adverse short- and long-term, and even catastrophic health consequences, ranging from:

(a) longer recovery time; to

(b) persistent symptoms which may linger for weeks or months (e.g, post-concussion syndrome), to

(c) permanent cognitive difficulties (problems with memory and concentration), and emotional problems (e.g. depression); to

(d) devastating degenerative neurological disease, such as chronic traumatic encephalopathy (C.T.E.).

The precise effects of mild traumatic brain injury such as resulting from concussion and repetitive sub-concussive hits, and the degree they increase the risk of long-term health problems is unknown and will vary tremendously among student-athletes; and

6. the need to work with coaches, athletes, and health care providers to create a safe reporting environment which encourages honest reporting by athletes of concussion symptoms (not only theirs, but their teammates).

Coaches

The key person in the concussion risk management program outlined in The Smartest Team is the certified athletic trainer (AT), but coaches play an important role as well, especially in the high school or youth football programs without access to an AT.  Because athletes, especially at the youth level, depend on their coaches for guidance, and need to feel comfortable in order to report their symptoms to their coaches, athletic trainers, teammates, and parents, and because young athletes’ beliefs about their coaches’ expectations on reporting may trump their own knowledge or intentions to report a possible concussion, it is critical that coaches:

• be trained to teach players heads up tackling and blocking (Pillar Two)
• be trained to watch for and recognize the signs of concussion.
• When an athletic trainer, team doctor or other medical professional with concussion education and training is not present on the sideline – which is strongly recommended – a coach should know to immediately remove a player from practice or play and arrange for an immediate evaluation by medical professional, and not allow the athlete to return to play that day, if he or she observes any of the following signs observed after a direct or indirect blow to an athlete’s head:
  • loss of consciousness (however brief);
  • balance or coordination problems (unsteady gait, athlete stumbles, walks sideways or is labored in their movements);
  • disorientation or confusion (inability to respond appropriately to the so-called “Maddocks” questions);
  • blank or vacant look;
  • visible facial injury in combination with any of the above.
• foster an environment where athletes feel comfortable reporting a concussion by actively, consistently, and repeatedly over the course of a season encouraging honest self-reporting of concussion symptoms by athletes and by employing use of a “buddy system” in which athletes are assigned to watch for signs or symptoms of concussion in designated teammates.  Recent studies have shown that coaches’ negative attitude about concussion reporting is the biggest barrier to such honest reporting. (2-5)

Coaches should always put athlete safety first, above winning. In other words, coaches need to be part of the concussion solution, not part of the concussion problem.

Health care providers

Primary care physicians (PCPs),  along with certified athletic trainers, treat the vast majority of concussions which do not require specialized care. Many admit to being unaware of current concussion management guidelines (Pillars Three and Four), or find the guidelines too confusing or cumbersome to put into practice.

Increased concussion education of PCPs is needed, especially now that all 50 states require that high school athletes (and, in some cases, athletes at the elementary and middle school level and playing in independent sports programs utilizing public facilities) suspected of having a concussion receive written approval from a clinician before returning to play (Pillar Five). One of the principal purposes of such laws – not to return athletes to play prematurely before their brains have healed – will be thwarted if clinicians do not know how to diagnose and manage concussion or are unaware of RTP guidelines and allow athletes to return to play sooner than recommended.

Smartphone apps

One way for athletes, coaches, parents, officials, support staff and medical personnel to become educated about concussions is by downloading concussion “apps” on their mobile devices. Because of their widespread use, portability and wireless connectivity, mobile phones can serve a unique and valuable function in bridging the significant gap in concussion education.

The key advantages of a mobile phone app as an educational tool are twofold: not only do they give the user the opportunity to download educational materials quickly, but they possess operating systems that support engaging and interactive solutions to learning. 

While there is also a need for smartphone apps to organize information on injury demographics, symptom timing, recovery milestones, and medical appointments, and to provide licensed health care professionals diagnostic screening tools, such as the Standard Assessment of Concussion (SAC) (6), Sports Concussion Assessment Tool (SCAT3  and Child-SCAT3 )(7,8), easily accessible across computing platforms, only four of the eleven applications identified in a 2013 study (9) as being assessment tools state that they are for use by health care professionals. Because use by parents and other non-medical personnel might carry significant legal liability, such applications should only be used as diagnostic screening tools by licensed health care professionals.

Education is not a panacea 

While increased concussion education is critically important, it is not a panacea.

 The effectiveness of concussion education in making contact and collision sports safer has not been well-studied, but the studies that do exist, while they suggest increased awareness, also show that athletes are still very resistant to self-reporting and that the culture of contact and collision of sports and pressure from and the attitudes of coaches, parents, and teammates tends to make athletes reluctant to report possible concussion.

A survey of Washington State adults a year after passage of that state’s groundbreaking concussion safety law, for instance, found that 85% of the study population was aware of the law and over 90% had a good understanding regarding the definition, diagnosis and potential severity of a concussion.

But, as a 2013 study in the prestigious British Journal of Sports Medicine noted, “Despite the interest generated through media exposure and public education programmes, there appears to be remain widespread misconceptions about the diagnosis and management of concussions, as well as knowledge gaps among athletes, parents, and coaches.” 

Moreover, a 2013 study suggests that, even when athletes have received concussion education and are aware of the dangers of continuing to play with concussion symptoms, most, unfortunately, remain willing to take that risk. An astounding 91 percent surveyed 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.  

Thus, comprehensive concussion education should be seen as just one prong in a multi-pronged approach to concussion risk management.

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Sources:

1. McCrory P, et. al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013: 47:250-258.
2. 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.
3. 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)
4. 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)
5. 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.
6.  SCAT3. Br J Sports Med 2013;47:259 (full pdf can be accessed without charge at http://bjsm.bmj.com/content/47/5/259.full.pdf )
7. Child-SCAT3. Br J Sports Med 2013;47:263 (full pdf can be accessed without charge athttp://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/JSM/A/JSM_23_2_2013_02_14_MCCRORYY_200872_SDC3.pdf)
8. Kutcher J, McCrory P, 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. (accessed March 21, 2013)
9. McCrea M. Standardized mental status testing on the sideline after sport-related concussion. J Athl Train. 2001;36:274-279.