There are many injury risks in football, but head injuries are the most concerning. Severe head injuries are rare in football, whereas concussions are relatively common. Football helmets have greatly reduced the severity of head injuries. However, helmets are not an effective tool for concussion prevention in football.

Education is an essential tool for reducing concussion risk in all contact sports, especially football. Concussion education must be for players, coaches, and parents. Common topics are risks of head injuries, concussion symptoms, and potential long-term consequences.

Proper concussion education is necessary because athletes underreport symptoms of concussions. If athletes continue to play with a concussion, they are more likely to have longer recovery times. They also put themselves at risk of second impact syndrome with another head impact.

The main goal of concussion education is to identify a possible concussion and remove the athlete from play. This does not prevent the first concussion. However, quick removal and management prevents worsening of the injury, improves recovery, and may help to decrease the likelihood of a future concussion.

For this reason, concussion education is vital to all groups involved in football.

This post will not discuss concussion risks and symptoms. Rather, it will focus on the reasons for implementing concussion education across many groups. Below are the main topics.

Why do Athletes Underreport Concussions?

Which Athletes are Likely to Underreport Concussion Symptoms?

Some Athletes are Unaware of Concussion Symptoms

Popular Concussion Education Programs for Athletes

Most Effective Concussion Education Programs for Athletes

Concussion Education for Coaches

Concussion Education for Parents

Why do Athletes Underreport Concussions?

Athletes who delay reporting or continue playing with concussion symptoms have longer recovery times than peers who immediately report symptoms.¹ Yet, many concussions still go underreported by athletes.

About 30% of adolescent athletes playing football, ice hockey, soccer, basketball, and lacrosse, who were in current care for a concussion, did not report concussion symptoms of a previous head injury.² Another study showed that only 47% of high school football players reported symptoms of a concussion.³

There are three main reasons for non-disclosure of concussion symptoms:⁴

1. Intra-personal including lack of knowledge, internal pressure, and male sex
2. Inter-personal like external pressure/support and other’s attitudes
3. Environment such as access to concussion prevention material and specific sport’s culture

These different reasons all inter-relate and influence an athlete’s decisions and behaviors.

For instance, a football player may not report concussion symptoms because he wants to continue playing for possible scholarships (intra-personal). He may be pressured by teammates and coaches who want him on the field (extra-personal). Additionally, his team’s culture may be based solely on toughness and sacrifice and lacking love and integrity (environment).

The multiple influences compound driving players to make poor decisions and act recklessly. Athletes who experience pressure from all groups—coaches, teammates, parents, and fans—are more likely to withhold concussion symptoms.⁵ Hence, concussion education is necessary for all groups.

Which Athletes are Likely to Underreport Concussion Symptoms?

Some athletes are at high risk of nondisclosure. For instance, male college athletes in collision and contact sports are more likely to not report concussion symptoms.⁶ They believe playing through a concussion would not be bad and concussion reporting was neither expected nor supported by those (players, coaches, family, etc.) around them. These athletes have more positive and fewer negative expectations and attitudes about playing with a concussion.

Athletes with higher sensation-seeking behaviors are also more likely to not disclose concussion symptoms.⁷ They like engaging in thrilling activities to increase stimulation and arousal. These higher risk profiles need to be identified. Then, involvement in effective concussion education programs must be completed to relieve internal pressures and the environmental stigma around concussions.

Some Athletes are Unaware of Concussion Symptoms

Some athletes have good knowledge of concussion symptoms, but studies have shown that many high school players do not know. Players are not aware that less common symptoms like nausea and amnesia can be from a concussion.⁸ At the same time, athletes who play club sports may not receive the same concussion education, if any, as school sports.

Giving a definition and symptom description of concussions to injured athletes has been shown to convince them that they sustained a concussion.³ Symptom education is the first step, but there also needs to be an understanding of the short- and long-term consequences of having a concussion and the risks of not reporting.

Popular Concussion Education Programs for Athletes

In 2010, the Centers for Disease Control and Prevention (CDC) partnered with the National Federation of State High School Associations (NFHS) to offer a free “Concussion in Sports” course. This course consists of a 25-minute video, six presentation slides, and nine follow-up questions. Although there are many other programs, the CDC’s has been the most used concussion resource among schools and organizations over the last 12 years.

Another free video course was launched in 2018 by TeachAids called Crash-Course (CC) concussion education. It is a 12-minute video that puts the learner in a first-person game situation. They experience a concussion and need to make a choice to play or sit and report symptoms.⁹ This new tool has been adopted by many U.S. youth football organizations, some U.S. Olympic committees, medical organizations, and several high schools.

There are some studies that show this course improves attitudes, perceived social approval, and understanding of concussions along with greater intention to report concussions. One study used three different tools—the CC videos, CDC’s video materials, and CDC’s written materials—on over 100 football players to determine their effectiveness.¹⁰ Although all materials improved multiple factors of concussion education and reporting at immediate and 1-month follow-up, the athletes watching the Crash-Course videos reported a greater intent to report concussions, more knowledge, and improved concussion-reporting attitudes compared with the other materials.

Another study looked at the combined use of both the CC and CDC’s video tools in over 300 football players.¹¹ This study found that there was significant improvement in athletes’ concussion-reporting intention, attitudes, subjective norms, and perceived behavioral control following each program individually and when combined. However, the athletes reported more enjoyment after the CC program versus the CDC materials. These studies demonstrate that concussion education can be beneficial for these higher risk athletes playing collision sports while some programs may be better than others.

Most Effective Concussion Education Programs for Athletes

Concussion education programs for athletes can come in a variety of ways. Who provides the education and how it is presented can greatly affect one’s motivation to learn, understanding of the material, and intent to make correct decisions.

In 276 colleges across the country, one study determined who presented the education, what materials were used, and what information was given.¹² It was found that over 90% of the athletic trainers delivered the information with only about 10% involving either physicians or athletic department administrators. Most programs involved a formal meeting with or without written materials. Only 30% or fewer schools showed a video, provided access to online materials, and/or hung an educational poster.¹²

In four of these colleges, athletes were asked their preference. Over 80% said they wanted information on concussion symptoms, risks of playing with concussions, and long-term consequences in a lecture or video. They preferred education to be delivered by an athletic trainer; however, about half wanted a physician or coach involved in the process.¹²

Athletes want concussion information presented by a credible source involving some technology. They want the coach involved to not only know the information but also endorse the mindset and reporting of concussions. The most effective concussion education programs provide the correct information by the right people with the best materials for the athletes to learn.

Additionally, teammates can greatly impact one’s intent to report concussions. Ten colleges tested a peer concussion education program for contact sport athletes.¹³ In addition to previous typical education, some teams completed peer-mediated education and discussion on concussion knowledge and symptom reporting. Two peer concussion educators were selected by their coach and trained by the athletic trainer to give an educational presentation with slides. They also led a discussion with worksheet exercises involving factors that influence concussion reporting.

Those involved in the peer-mediated program showed greater concussion knowledge, intention to report one’s or another teammate’s concussion, and return-to-play protocol knowledge.¹³ They also had improvements in attitudes, subjective norms, and behavior control towards concussion; hence, they were more likely to discuss concussions with teammates and athletic staff. Peer pressure can be highly impactful for student-athletes, so encouraging a team culture that praises concussion reporting is essential in football.

Concussion Education for Coaches

Concussion education is vital for coaches because coaches’ expectations and team culture can influence an athlete’s decision to report concussion symptoms. Coaches need to be educated on concussions for several reasons:

1. Knowing the recognizable signs and reported symptoms of concussions encourages appropriate removal from play and necessary medical evaluation.
2. Understanding the risks of playing with a concussion and the long-term consequences enables the coach to look out for players’ best interests as human beings.
3. Incorporating coaches in the education of athletes can help deepen relationships with the players and promote a culture that takes head injuries and concussion reporting seriously.

As of the year 2020, all states except Georgia require that high school coaches receive educational materials or undergo training regarding concussions.¹⁴ However, less than half of the states extend these laws to youth sports organizations like clubs.¹⁴ Therefore, club coaches are less likely to be aware of concussion-education and -management plans and scored lower on concussion-knowledge questions. This can be a big flaw for youth sports that may put children at risk.

Coach concussion education should be addressed by all organizations. USA Football’s Heads Up Football (HUF) educational program is a great option for all coaches. It includes concussion awareness along with training regarding proper techniques for blocking and tackling.¹⁵ There are also more accessible options listed below.

Concussion Education for Parents

Similarly, parental pressures can greatly influence an athlete’s perception and choice to disclose concussion symptoms. Also, parents may be the least knowledgeable regarding concussion symptoms and behavioral responses involving concussion scenarios.¹⁶ Hence, concussion education for parents can effectively reduce concussions and improve concussion reporting among youth athletes.

Knowing concussion symptoms is important for parents to improve concussion identification. A survey of 1062 parents of middle school children asked to list symptoms of a concussion in an open field text box followed later by responding yes/no/maybe to 25 possible concussion symptoms.¹⁷ Five percent of parents noted that they did not know any concussion symptoms. Over 85% of parents identified dizziness, blurred vision, and balance problems as symptoms of concussion with the given list, but only 44.4%, 16.5%, and 3.5% wrote these respective symptoms in the free-response box earlier in the questionnaire.

This exploits the need for concussion education for parents, especially regarding concussion symptoms. However, parents should also be informed of head injury risks in football and the many ways they can help prevent concussions in their children.

There are a couple programs that include concussion education for parents. The CDC has a free toolkit for coaches, parents, and health educators called “Heads Up: Concussion in Youth Sports.” Similarly, Concussion Wise^TM by Sports Safety International is a free, online, 30-minute course designed for coaches, parents, and healthcare professionals to improve concussion knowledge.¹⁸ These would be great for all parents to take each year to learn and review concussion information.

Summary

Athletes, especially football players, continually underreport symptoms of concussions. There are many socio-ecological factors that go into the non-disclosure including internal perceptions, external pressures, and one’s environment.

Proper concussion education regarding concussion symptoms, risks, and long-term consequences of playing through a concussion can increase concussion reporting among athletes. This will keep children safer by improving outcomes following a concussion and preventing further injury.

More importantly, healthcare professionals and coaches involved in the delivery of info that includes a lecture and/or video can increase the effectiveness of athletes’ understanding and intent to report future concussions. Peer-based education may be valuable by improving team culture and the stigma around playing with verses reporting a concussion.

Furthermore, because athletes can be influenced by coaches and parents, both groups need to be educated. Coach and parent education should include concussion symptoms, head injury risks, and prevention of concussions.

Concussion education for players, parents, and coaches is essential to reduce the risk of head injuries in football.

References

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