Concussion management is potentially complicated by the lack of reporting due to poor educational intervention in youth athletics.
Determine if a concussion-education video developed for high school athletes will increase the reporting of concussive injuries and symptom recognition in this group.
Cross-sectional, between groups.
Athletes participating in South Carolina interscholastic athletics.
High school athletes (N = 68; males n = 42; females n = 26; mean age = 14.78 ± 1.38 years) participated in this study. The athletes were randomly assigned into 2 groups: concussion education (n = 34) and control (n = 34).
Participants were administered a survey before and after watching a video about concussion incidence, symptoms, and reporting conditions (intervention group) or a nutrition video (control group). Total symptom score and survey items served as dependent variables. Examination of group differences was performed through χ2 analyses and repeated-measures analysis of variance (ANOVA) calculations in SPSS 19.0 (SPSS Inc, Chicago, IL). Significance levels were set a priori at .05.
Of all participants, 70.5% (48/68) reported not knowing the signs and symptoms of concussion before the study, and 26.5% (n = 18) reported having had at least 1 prior concussion. A statistically significant difference existed between those reporting having vs. not having knowledge of the signs and symptoms of concussion on total symptom score at baseline (t1,66 = 2.17, P = .038). Repeated-measures ANOVA calculated a statistically significant difference for concussion symptom recognition before and after the intervention (F1,66 = 7.47, P = .008)
A large percentage of high school athletes do not know the signs and symptoms of concussion. After an educational video, participants' symptom knowledge and previous concussions reported increased. Education of those involved in athletics using a standardized tool may increase reporting and aid in the assessment and management of concussion in this population.
Each year an estimated 7.7 million youths participate in high school sports.1 The rising participation of adolescent athletes increases their risk for injury. In high school athletics, an estimated 300 000 head injuries occur annually, with 90% of these injuries classified as concussions.2–5 It appears that athletes report their first concussion between the ages of 10.8 and 14.8 years, and by the start of high school, 53% of student-athletes are now reporting a history of at least 1 concussion.6,7 Moreover, researchers8 have found that more than 50% of athletes do not report concussions when they occur.
Several reasons have been suggested for this lack of reporting. First, the participants may not think a head injury is sufficiently serious based on teammates' prior head injuries.8 Second, players may not want to be withheld from competition.8 Third, players may have a lack of knowledge related to the risks and potential consequences of concussion.8 McCrea et al8 concluded that more than one-third of the players who failed to report their injury did not recognize that they had sustained a probable concussion based on their symptoms. When provided with a definition of concussion and description of injury signs and symptoms, the players admitted having sustained a concussion over the course of the football season.8
Kaut et al9 found similar results in his study of high school students just before collegiate play. Of the 15.8% of football players actually diagnosed with a concussion, 25.2% failed to report dizziness to athletic trainers or coaches while playing.9 Moreover, an examination of athletes' understanding of complications associated with a head injury revealed that 56% of all athletes studied, including female soccer athletes, reported no knowledge of the possible consequences after a head injury.9
The Consensus Statement from the First International Conference on Concussion in Sport10 on concussion recognized that education of athletes, referees, administrators, parents, coaches, and health care providers is a mainstay of progress in this field. Since the 2004 Zurich meeting, numerous position statements from several professional organizations have supported the need for educational interventions.10–13 This need for education has resulted in several organizations developing educational tools for multiple populations. Studies have been conducted to examine the knowledge of coaches,14–16 administrators,17 and parents regarding concussion.6,16–18 However, little research has been conducted on interscholastic athletes' knowledge of concussion.14–18
The Centers for Disease Control and Prevention (CDC), along with partner organizations, created “Heads Up: Concussion in High School Sports.”19 This tool kit includes educational materials such as a video, a wallet card listing signs/symptoms, posters, fact sheets, and other concussion-related resources. Sarmiento et al20 surveyed 1009 high school coaches (31% of all coaches) who requested the tool kit.20 Eighty percent of the high school coaches who received the tool kit found it very helpful in the recognition and management of concussion in their high school.19,20 Studies indicate that the least-used tool was the CD (59% of coaches used) and the most commonly used tools were the booklet (79%) and wallet card (60%).19,20 Thirty-four percent of the coaches reported that they had learned something new from the tool kit, especially when it came to identification of symptoms of concussion, second-impact syndrome, and the length of recovery.20
In an attempt to standardize educational interventions, educational videos have been developed by the CDC, the National Academy of Neuropsychology, and the National Hockey League, in collaboration with the National Athletic Trainers' Association, to provide basic knowledge.21,22 Regrettably, these videos (1) are the least used in the CDC tool kit, (2) focus on the catastrophic consequence of second-impact syndrome, and (3) use sport-specific (hockey) professionals and clinicians discussing basic knowledge and long-term ramifications of concussion. Unfortunately, many high school athletes do not believe that the catastrophic consequences of repeated injuries will happen to them, and without a similar environment and population, these athletes may disassociate from the facts of the injury the video is trying to address.
Researchers and clinicians are trying to identify a way to standardize concussion education for all involved in athletics. However, few studies have examined the effectiveness of any type of educational intervention, specifically those using a standardized video, as an educational method. Furthermore, the ideal type of educational intervention or delivery method for concussion education in high school athletes has not been established. The aim of this study was to determine if a concussion-education video developed for high school athletes would increase the reporting of concussive injuries and symptom recognition. It was hypothesized that the participants who watched the video would report more concussive injuries and identify concussive symptoms at higher frequencies than those in the control group.
A convenience sample of high school athletes aged 13 to 18 completed a concussion-education survey during fall preseason in South Carolina. Inclusionary criteria included any gender, age 13 to 19, and participation in fall junior varsity and varsity athletics. Exclusionary criteria included English as a second language.
A total of 84 athletes were approached to participate in the study. These athletes were a sample of convenience from 3 local Division I high schools with interscholastic volleyball and football. Participants and guardians read and signed university-approved human subjects parental permission and minor assent forms before enrollment in the study.
Parental permission and minor assent forms were obtained from 68 athletes who were included in the study as participants. The participants were randomly assigned into 2 groups: concussion education (n = 34) and control (n = 34). The concussion-education group was administered a survey before and after watching a 9-minute video about concussion. The control group was taken from the same population and administered a survey before and after watching a nutrition video.
This questionnaire combined several previously used student-athlete surveys and was specifically designed to emphasize simplistic wording and ease of administration in the adolescent population.6,8,23,24 The questionnaire was developed to obtain basic information about the participants' knowledge of concussion symptoms, previous history of concussion, if and to whom they reported the concussion, and reasons for not reporting. This short questionnaire consisted of 14 items and a symptom recognition checklist. The questionnaire consisted of global demographic information, concussion history, and reporting questions, as well as the symptom recognition checklist. A specific item within the questionnaire asked, “Do you know the signs and symptoms of concussion?” to determine the athlete's self-awareness of concussion symptoms. In the symptom recognition checklist, participants were asked to select all signs and symptoms of concussion. Every correct symptom identified received 1 point, for a total maximum score of 17.
Content validity was evaluated during the revision of the initial questionnaire by administering the survey to 8 student-athletes (age = 14.23 ± 1.18 years; 5 boys and 3 girls) who were not included in the final assessment. No items were removed or changed because of the examination of content validity. The final questionnaire examined the number of years in the participant's sport, previous history of concussion, knowledge of symptoms associated with concussion, weight, height, date of birth, and symptoms of concussion. The questionnaire can be found in Figure 1.
Test-retest reliability calculations were performed on the questionnaire to enhance the validity of findings. A sample of 9 athletes (14.18 ± 1.23; 4 boys and 5 girls) from a different school system was used to assess reliability of the questionnaire. The questionnaire was administered after researchers read the instructions to obtain baseline data and then, to mimic the study design, administered 15 minutes later. Test-retest reliability was r = 0.97.
The concussion-education video was developed as a 9-minute video that covered topics such as:
Mechanism of concussion
Sports in which concussion occurs
Signs and symptoms
Reasons not to report
Whom and when to report
Potential long-term effects
This content was selected as pertinent for adolescent athletes following the First International Conference on Concussion in Sport Guidelines.10 The video was constructed using an approximately 9-minute script created by the researchers. The video answered important questions many adolescent athletes might have pertaining to head injuries or concussions, such as:
What is a concussion?
How do concussions happen?
How do I know I have a concussion?
What are the signs and symptoms of concussion?
What is the importance of reporting my injury?
Whom should I report my injury to?
What is the difference between just getting hit in the head and having a concussion?
How are concussions managed?
When will I be able to play again?
The video was created to flow through each aspect of concussion knowledge listed above. The investigators believed the flow of the information was the most logical to enable the high school athlete to stay engaged and learn from the video. However, the video was developed to provide more information than the questionnaire examined, and therefore the video and questionnaire were not linked in order of content or questions. See Table 1 for the abridged script.
Content validity was examined for the video. Content validity was established by providing the video to 12 certified athletic trainers to evaluate the format, flow of material, and whether the material provided the basic level of knowledge that adolescent athletes require. There was 100% agreement that the video provided age-appropriate basic knowledge of concussion.
The nutritional education video was a 10-minute script obtained from McGraw-Hill's Fitness Video Series. This video does not have any reference to head injuries or concussion. There were no financial incentives or obligations for using the video in this study.
Data Collection Procedures
During fall preseason, the investigators attended athletic parent and team meetings and explained the research study, including the risks and benefits associated with the study. Questions regarding the study and participation in the study were answered and both guardians and students were given time to decide whether they would participate in the study. Once guardian permission and minor assent were obtained, the student was enrolled in the study. Once enrolled in the study, the participants were gathered into 1 classroom.
All participants were given the preintervention questionnaire and clearly read the instructions by the researchers. After all participants completed the questionnaire in a group setting, participants were randomly assigned into the following groups: concussion-education group (concussion video) and control group (nutrition video). The concussion-education group was asked to stay in the classroom and the control group was escorted to a second classroom. The respective videos were administered to each group, and immediately after the conclusion of each video, the participants were readministered the survey.
Descriptive statistics were calculated for demographic data. Frequencies of signs and symptoms were analyzed within the pre-post questionnaire design. All data were examined for outliers during the analysis of preintervention and postintervention main effects and interactions.
Examination of group relationships for the independent variables of year in school, ethnicity, gender, and school attended were assessed through χ2 analyses. An independent-samples t test was calculated to determine differences between those who reported they knew and those who reported they did not know the signs and symptoms of concussion on total symptom score on the symptom recognition checklist at baseline. A repeated-measures analysis of variance (ANOVA) was used to determine group differences between groups and total symptom recognition score. Significance was set a priori at .05. All statistical techniques were computed using SPSS 19.0 (SPSS Inc, Chicago, IL).
Sixty-eight participants (males n = 42; females n = 26; age = 14.78 ± 1.38 years) were included in this study (Table 2). Of the participants, 26.5% (n = 18) reported having a previous history of concussion during baseline testing. Athletes diagnosed with a concussion initially reported the concussion to (1) the athletic trainer (17%; n = 3), (2) the coach (22%; n = 4), or (3) no one (28%; n = 5). Of all of the participants, 70.5% (n = 48) reported having no knowledge of what concussion symptoms can occur during injury when asked, “Do you know the signs and symptoms of concussion?” An independent-samples t test revealed a statistically significant difference between those reporting yes and no to having knowledge of concussion signs and symptoms of concussion with regard to total symptom score on the symptom recognition checklist at baseline (t1,66 = 2.17, P = .038); those who said yes, they knew the signs and symptoms of concussion, did indeed have a higher total symptom score. Interestingly, all athletes who reported a history of concussion also reported yes to having knowledge of concussion symptoms at baseline. Table 3 lists the frequencies for identification of each symptom before and after the intervention.
Participants were randomly divided into 2 groups of 34 each (concussion education and control). There were not significant differences between groups for year in school (χ24 [N = 68] = 6.432, P = .783), ethnicity (χ24 [N = 68] = 4.25, P = .381), gender (χ22 [N = 68] = 2.68, P = .291) or school attended (χ23 [N = 68] = 0.210, P = .792).
Previous History of Concussion
In the control group, 17.6% (n = 6) reported a previous history of concussion, while 35.3% (n = 12) of the educational intervention group reported a previous history of concussion. Although the educational intervention group reported more participants with a previous history of concussion, this difference was not statistically significant. This can be explained by the small sample sizes per cell, which limited power for this analysis (χ22 [N = 68] = 2.72, P = .168, η = 0.20). There was a statistically significant difference in previous history of concussion before and after intervention, with the education intervention group reporting 12 concussions at baseline and 15 after the video intervention, whereas the control group remained at 6 reported concussions (χ22 [N = 68] = 5.58, P = .034, η = 0.286; Table 4).
For the 17 items comprising the symptom recognition portion of the questionnaire, the mean number of correct responses for each group is presented in Table 4. Repeated-measures ANOVA revealed a statistically significant difference for time (concussion symptom recognition before and after the intervention; F1,66 = 49.05, P = .000, η2 = 0.426) and group (education versus control) by time interaction (F1,66 = 7.47, P = .008, η2 = 0.102); but not group alone (F1,66 = 0.340, P = .562, η2 = 0.005; Figure 2). This finding suggests that even though the control group started with a higher nonsignificant total symptom score, after the video intervention, the education group was able to correctly identify significantly more symptoms than the control group. Further examination of symptom recognition revealed that the educational intervention group recognized 77.3% of the concussion signs and symptoms at baseline and increased to recognizing 89.9% of the concussion signs and symptoms after the educational video. In the control group, 79.5% of the concussion signs and symptoms were recognized at baseline testing; this remained relatively constant after the nutrition video with 82.5% of the concussion signs and symptoms being recognized. Although this is not a statistically significant increase in percentage of concussion symptoms identified correctly, the ability to correctly identify more symptoms will aid the participant in recognizing a concussive injury and correctly reporting the injury to appropriate medical personnel.
We found that with use of a standardized concussion-educational video, high school athletes may be better able to correctly identify concussion signs and symptoms and improve their reporting of concussion. This finding is supported by other researchers that examined concussion knowledge and educational interventions.14,15,24 Bramley et al25 found that high school soccer players with any education about concussion were more likely to report a concussion to a coach or athletic trainer compared to those athletes with no concussion education. Providing student-athletes with an appropriate definition of concussion that is easy to understand increases the number of recalled concussive injuries.
This study found that 26.5% of the participants reported a previous history of concussion. This is higher than commonly reported incidence rates of 5% to 15% in high school athletes.7,8,26,27 These previous reports of incidence may be hindered by a lack of definition of concussion. Valovich-McLeod et al6 described how athletes' ability to self-report history of concussion during preparticipation physicals was limited by the wording and definition of concussion. The use of terms like ding, bell rung, concussion, mild traumatic brain injury, etc, can alter identification and reporting of a head injury.6 Having a clear definition and understanding of the meaning of concussion for youth and adolescents may impact reporting. A survey of adolescent coaches acknowledged that players infrequently report concussions, so they found that it was imperative that the education be focused on the players themselves.14,20
Even with the heightened media and awareness of concussion, we still found that before the intervention, when asked the question; “Do you know the signs and symptoms of concussion?” 70.5% of the high school athletes sampled did not know the signs and symptoms of concussion. Interestingly, those athletes who self-reported knowing the signs and symptoms at baseline scored significantly higher on the total symptom score during the symptom recognition checklist portion of the questionnaire. Kaut et al9 had similar findings, reporting 56% of athletes indicated a lack of understanding of the signs and symptoms of concussion. These findings are alarming, as symptom presentation is the most common reason an athlete would report to an athletic trainer or coach. When surveyed, 85% of certified athletic trainers used symptom checklists as part of the concussion assessment battery.28–30 Although the Kaut et al9 study was published shortly after the release of the CDC's Heads Up program, in 2013 there are still signs that the dissemination of education has not been widespread among those involved with high school athletics.9
Despite the fact that a significant amount of athletes did not know the signs and symptoms of concussion before this study, we found that using a standardized educational video resulted in high school athletes' ability to identify significantly more concussion signs and symptoms. An athlete's lack of symptom knowledge associated with concussion, then, decreases the athlete's recognition of concussion and resultant failure to report the injury. Delaney et al31 found similar concerns when only 20% of professional athletes who were experiencing a concussion actually realized that they had suffered the injury. The findings of Delaney et al31 provide evidence that educational interventions supply information that athletes can use to report concussion. Although there was not a statistically significant increase in the number of correctly identified symptoms, having the knowledge of concussion symptoms and being able to recognize them correctly will aid athletes and clinicians in reporting. Enabling athletes to recognize the signs and symptoms of concussion increases their likelihood of reporting the concussion to appropriate personnel, which can decrease the risk of secondary consequences of concussion.
Few researchers have used a video education intervention in isolation. Echlin et al17 examined an interactive computerized module and a preexisting hockey concussion DVD to educate hockey players about concussion. Many researchers have used a mixed delivery of education, including methods such as PowerPoint presentations, video segments, demonstrations, case studies, and personal testimonies from collegiate and professional athletes and question and answer periods; however, these methods require trained administrators and time.17,25,32 In many athletic situations, the number of clinicians available to educate those working with athletics is limited, and thus, having a standardized video that can be played at any meeting or venue is useful. Moreover, although these researchers found improvement in knowledge scores over time, no conclusions have been reached about the most appropriate method of intervention or knowledge retention.
Basic concussion-educational literature is being disseminated and is trickling down to the clinicians who are ultimately responsible for the care of young athletes.33 The method of intervention delivery, however, is still questionable for clinicians and educators. Provvidenza and Johnston34 suggested that these educational models be representative of learning needs associated with the age of the participant and type of knowledge required.34 We found that a standardized video improved reporting and symptom recognition in interscholastic athletes immediately after the intervention. These findings support using technology such as standardized videos as a viable option for educating patients by athletic training students and clinicians. However, additional research should be conducted to determine if a standardized educational video would be effective in long-term knowledge retention.
The seriousness of concussive injuries has recently come to light with heightened media coverage of high-profile professional and collegiate athletes' removal from participation due to concussion. Additionally, since the inception of the Washington State concussion law (Lystedt Law) for head injuries in adolescents, many state and federal legislation policies have been proposed and implemented. Currently, all 50 states plus the District of Columbia have passed some form of head injury legislation for adolescent athletes.35 Although legislation in each state has different components and wording, all current legislation involves some educational component for parents, coaches, and student-athletes.35
A short video was developed to provide basic standardized concussion information specifically for high school athletes. Educating high school athletes regarding concussion increased the number of concussions reported. Use of a concussion-education video provides a standardized approach that is easy to administer and provides a message that crosses over gender and sport, using multiple learning styles including visual, verbal, and somatosensory to enhance knowledge of concussive injury.
Most education regarding concussion is completed because of experience or education provided by certified athletic trainers. When concussive injuries occur outside of athletics or at times when experienced health care providers are not accessible, relying on experience or health care professional–supported education may not be feasible. The video used in this study was well received by the coaches, athletic directors, and athletes regarding its usefulness and ease of implementation into high school athletics. Obtaining buy-in from all parties involved in athletics will help with implementation of educational interventions for concussion to keep athletics safe for youth.
Unfortunately, the ideal delivery mode and educational content for interventions appropriate to each group (such as youth, coaches, administrators, parents, etc) receiving educational interventions has yet to be identified. It may not be feasible for every school, clinician, and/or coach to develop population-specific videos. However, the goal should be to provide at least the basic information regarding concussion (what is a concussion; how do I know I [my child/my athlete] have/has a concussion; symptom recognition; whom to report to; and the consequences of the injury). When a population-specific video is not available, using commercially available videos can provide the same standardized basic information for each population. Although this study supports the use of a standardized video for concussion education, it is still acknowledged that there is a need to continue to refine available videos and develop new multimedia and technological formats that will capture most audiences and provide appropriate knowledge necessary for safe participation in sports. Additional research should be conducted to provide continuing education for clinicians to implement standardized video education in patient care.
There are several limitations of this study that warrant some discussion. First, the sample included both male and female athletes. Sport choice was not limited and was not assessed as a confounder for concussion education. This study was completed during the fall, when football and volleyball are the prominent sports. Football is considered a high-impact–collision sport that represents an increased risk for concussive injuries and has received significant media attention. Volleyball, on the other hand, may receive less attention and participants may have less knowledge of concussion. Previous education due to sport participation may play a role that was not accounted for. Future studies should examine the role of the athletic trainer and previous sports knowledge in the education provided to athletes.
Second, survey research is limited to the time at which the survey was administered. Test-retest reliability was conducted with 15 minutes between testing sessions. During the data collection, the questionnaire was administered twice, once before and once immediately after a 9- or 10-minute video. No additional follow-up testing was conducted. The methodology of this study does not ascertain the nature of long-term recall of the information obtained from the video. Further, recalling concussion history throughout an interscholastic athlete's lifetime may prove difficult. Future research should be conducted to complete a more thorough validation of the mode of delivery for ultimate retention of the concussion intervention.
Third, the sample size was small, and although random assignment was conducted, differences existed at baseline for those with previous concussions. The subsample of adolescents who went through the intervention was participating within athletics at schools where athletic trainers were present at practices and games. Future research should be conducted to increase the sample size and ensure groups are equal at baseline testing within schools with and without athletic trainers to assess the educational intervention.
Education increases an athlete's knowledge of concussions, which has been found to influence the reporting of concussive injuries to medical personnel. This study found an increase in the reporting of concussion history and knowledge of symptoms after watching a concussion-education video. Although clinicians may be effective and efficient at educating athletes, because of limitations in time and resources in some settings, the availability of an in-person educational session for every team, season, meeting, or class may not be feasible. A standardized video ensures that the same information is provided every time and decreases the amount of resources necessary to conduct educational sessions for everyone involved in athletics.
Implementing a concussion-education video may prove valuable in the reporting, evaluation, assessment, and return-to-participation decisions for allied health care providers working in the high school athletic system. This research supports using a video to standardize the education provided by any clinician in an interscholastic setting. Athletic trainers and/or coaches should take a proactive approach to educate all athletes, parents, and school officials about concussive injuries. Standardized videos may be an appropriate medium to educate athlete, parents, students, and clinicians about concussions. This will aid in creating a plan, if and when concussive injuries do occur, for safer athletic practices in high school athletes.
Dr Hunt is currently an Assistant Professor in the School of Health and Rehabilitation Sciences at Ohio State University. Please address all correspondence to Tamerah N. Hunt, PhD, ATC, School of Health and Rehabilitation Sciences, Ohio State University, 453 West 10th Street, 218 Atwell Hall, Columbus, OH 43221. Tamerah.firstname.lastname@example.org.