Wednesday, February 27, 2013

Time to Improve Player-Coach Dialogue About Concussions

In the US, nearly 200,000 athletes per year visit emergency rooms for treatment of concussions. It’s unknown how many go unreported. Estimates are that more than half of athletes who have symptoms of a concussion do not report them. In addition to loss of consciousness, noon-specific symptoms include headache, dizziness, nausea and difficulty focusing on school work. Recent studies emphasize that repeated concussions can lead to permanent brain damage and severe, long-term cognitive and emotional disturbances. So, reporting is critical. In 2009 Washington state passed legislation requiring coaches, athletes and parents to be educated on concussions and brain injury. In a new study from the University of Washington and Seattle Children’s Hospital, researchers asked the question, does improving concussion knowledge lead to better symptom reporting? They find that despite high school athletes understanding the signs, symptoms and consequences of concussions, there are still barriers preventing them from reporting a possible concussion.

The researchers interviewed nine groups of high school athletes from football (American), girls and boys soccer (a total of 50 athletes in all). The groups were presented with four hypothetical scenarios describing a collision along with immediate symptoms and those that persisted into the next day. They were then asked a series of questions designed to evaluate their knowledge of concussions and their attitudes toward reporting symptoms and continuing play. All questions were open ended, resulting in a general discussion of the issues.

After reviewing the interviews, he researchers found several themes that were common among the young athletes:

”Athletes know concussions are dangerous.” The groups were able to describe many of the signs and symptoms of a concussion. They understood obvious signs such as loss of consciousness as well as non-specific symptoms such as headache, dizziness and nausea. They also understood the short- and long-term ramifications of a concussion like difficulty in school, permanent brain damage and death. In fact, one player commented, “that’s life or death out there… most people don’t realize that you can die from a concussion.” In this regard, concussion education programs seem to be quite effective in improving young athletes’ knowledge about head injuries.

”Most athletes would still play with concussive symptoms.” Despite understanding concussion symptoms and risks, many athletes stated that would still play after a collision that resulted symptoms. They wanted to see how they felt and if the symptoms subsided before reporting them. Some said that they might take a short break but would definitely go back in. No one said they would immediately stop playing because of a headache or mild dizziness.

”Athletes want to keep playing.” Players play because they enjoy the sport and they train hard to achieve success. So they were not excited about the thought of removing themselves because of something seen as a minor headache.

”It’s hard to tell if you’re injured.” Players were quick to point out that many non-specific concussion symptoms might be due to something else. For example, dehydration, migraine, colds, flu, etc. could be possible explanations for headache and dizziness

”You’re supposed to play if you’re injured.” Part of the current sport culture is to play through the pain. Athletes who do this are often seen as tougher and more dedicated. Non-specific concussion symptoms, headaches and nausea, are seen by this group of athletes as rather poor excuses for sitting out.

”Don’t want to let the team down.” Athletes identify strongly with their team. They felt that the worst possible scenario was to come out of a game because of what might be viewed as a minor injury, then watch their teams lose. They worried that they would be blamed for the loss and seen as not being fully invested in the outcome.

”The coach matters.” This was a major revelation. The researchers found that discussions about a potential concussion varied more by team that by sport or gender – the common factor was the coach. Some players said they received negative messages from coaches about concussion injury reporting. They felt that coaches viewed them as weak or overreacting to a minor problem. Troubling comments from the athletes were, “…they say ‘when you’re hurt, come out’, but they don’t’ mean it”, “…it was pounded into us like, ‘suck it up. You’ll be fine if you get knocked a bit’. So we didn’t really know where to draw the line”, and “Coach said that if he had to come out there and get you off the field there better be a bone sticking out”. It’s important to point out that these and similar comments came from both male football players and female soccer players. On the other hand, positive messages from the coach and a sense of player concern encouraged players to report their symptoms. A few players noted that their coach taught styles of play that reduced the risk of concussion and expected players to mention if they felt dizzy after a hit.

Given the results of this survey and discussion, two key conclusions can be drawn. The first is concussion educations programs are effective in raising awareness and teaching high school athletes about the signs, symptoms and dangers of concussions. Players clearly understand both obvious and non-specific symptoms. They also understand what could happen to players who continue to play with a concussion. Thus, high school players seem to know a great deal about concussions. Despite this, most players are hesitant to report non-specific symptoms and would continue to play.

Second, the major barrier to reporting concussions appears to be communication and the environment and culture created within the team. What seems to be the key is the message sent by the coach to the players. Unless coaches deliver a message that it is OK to report symptoms and that concussions should be taken seriously, players sense that it is not acceptable to stop playing because of a non-specific symptom such as headache or dizziness. Players are concerned that they may be wrong about having a concussion (symptoms may be due to something else) and that they may suffer negative consequences if they come out.

This latter conclusion places coaches as the center of the battle to address sports-related concussions. Their attitude, message delivered to the players and team atmosphere are critically important in facilitating concussion symptom reporting. Given this the study’s authors suggest that along with increase knowledge, educational programs should be designed to improve communication and foster symptom reporting. Coaches should work towards being more approachable and deliver the message that it is OK for athletes to report symptoms like headaches, dizziness and nausea when they occur after a collision. They need to discourage player attitudes of playing through the pain and win at all costs.

Nearly everyone agrees that concussions are a serious medical condition. However, until better objective tools are developed to diagnose a concussion, coaches must rely on players self-reporting symptoms. Often, players are hesitant to do so. To combat this, that coaches need to do a better job of facilitating communication, assuring players that it is OK to sit out with a possible concussion and promoting an attitude that player health trumps team results.


Chrisman SP, Quitiquit C, Rivara FP (2013) Qualitative study of barriers to concussive symptoms of reporting in high school athletics, Journal of Adolescent Health, 52: 330-335.