Evolution of concussion education and knowledge

Early epidemiological data alerted the sports medicine community to the alarming number of potential sports concussions.15 An early survey of professional athletes first identified gaps in knowledge, understanding and management of concussions among players.16 Specifically, results indicated that athletes had been provided with little education about sports concussions, did not recognise the signs and/or symptoms of concussions, and had misperceptions about the injury. Subsequent surveys of collegiate athletes continued to indicate that a substantial proportion of collegiate athletes either did not know how to define a concussion or had limited understanding of the steps needed to best manage a concussion, and continued to play while symptomatic (with up to 60% of athletes reporting that they continued to play with concussion symptoms).17 ,18 It is estimated that between 1.6 and 3.8 million sports concussions occur annually in the USA.19 ,20 Surveillance studies suggested concussions accounted for up to 9% of all sport injuries and confirmed the high risk of concussions in youth, especially in contact sport.21–23 The combination of poor/limited knowledge about concussions and high rates of injury provided an impetus to improve education efforts.24

Education materials

The US Centers for Disease Control and Prevention (CDC) was charged under the Children's Health Act of 2000 to implement a national traumatic brain injury education and awareness campaign.25 The CDC designed a toolkit using quantitative and qualitative methodologies including surveys, focus groups and expert opinions, to improve education and knowledge dissemination. A sample of 1009 coaches was mailed the Heads Up: Concussions in High School Sports toolkit and nearly 500 coaches responded to follow-up phone surveys.

This pilot study survey indicated that most coaches expressed strong interest in obtaining more information about concussions, as most did not have a comprehensive concussion programme in place and lacked proper information. The kit was utilised by 90% of coaches within 6 months, and favourably rated for its usability and information.26 A subsequent follow-up study targeted the 1009 US high school coaches who had ordered and received the toolkit. Of the 333 who responded, 90% of coaches who responded had used the kit within 6 months, 82% reported the materials to be extremely useful and 50% reported the toolkit had changed their views on the seriousness of concussions.26 ,27 Another follow-up study surveying over 5000 coaches published similar results for the percentage of coaches who used the toolkit and provided high ratings for usefulness.28

Information about sports concussion has grown considerably and, at present, a wide range of media is used to educate athletes and others about concussions.11 ,29 There are printed materials, including handouts, pamphlets, posters and concussion cards (for instance, SCAT3, ThinkFirst Guidelines, Sports Legacy Institute, Barrow Brain Book; Brain 101: The Concussion Playbook). Position statements from various professional organisations such as the International Consensus Group,5 American Academy of Neurology,30 American Sports Medicine Society,31 National Athletic Trainer's Association (NATA),32 National Academic of Neuropsychology,33 American Academy of Pediatrics34 and Canadian Pediatric Society,35 have been published and posted online to promote knowledge and evidence-based practice. Didactic lectures such as the ThinkFirst Concussion Roadshow have also been used to encourage more interaction between knowledge source and end user.36 Websites have become a popular method for providing information to target populations.37

Additionally, a significant number of online webinars that provide training for target populations (eg, Parachute Canada, CDC's Heads Up Toolkit, Concussion Awareness Training Tool (CATT))38–40 have become readily accessible. Some webinars reviewed for the purpose of this study were connected to commercially available products. A recent review identified approximately 40 commercially available applications that were available for handheld devices.41

Education changes athlete behaviour

Despite the proliferation of information available to the consumer, few publications have summarised outcomes and effectiveness of current education efforts.37 The primary method used to measure knowledge about concussions and concussion management has been surveys (table 1).12 For athletes, results from surveys are mixed. Continuing to play while symptomatic following a concussion is a consistent finding among surveys of athletes of all ages. Among youth hockey players, studies have suggested the percentage of athletes continuing to play despite being symptomatic ranges from approximately 25% to 60%.18 ,42–45 In fact, one study using anonymous surveys with elite minor hockey players found that their reported incidence of concussion was up to 30 times higher when compared with official injury reports.46 Among collegiate athletes playing football, hockey, soccer and rugby, the rates of unreported concussions ranged from 20% to 50%.17 ,42 ,47

Prospective studies have found that athletes significantly under-report concussive symptoms to their ATCs as compared with symptoms reported in a confidential setting.48 Furthermore, several studies suggested report of symptoms is not consistent with performance on cognitive testing.49 ,50 Surveys that included tests of athlete's knowledge identified gaps in their knowledge base.9 ,17 ,18 ,42 ,48 ,51–57 A majority of athletes recognise some, but not all symptoms associated with concussion, and often do not attempt to discriminate between concussion and non-related symptoms. An interesting trend was that athletes who had a history of concussions were more likely to correctly identify symptoms than those with no previous history of concussion.17 ,18 ,42 ,48 ,51 ,55–57 Moreover, select studies suggested that athletes who had received concussion education were more likely to state it was not okay to keep playing after concussion.51 However, context (eg, an important game) was likely to influence player disclosure to ATCs.51 ,53

Education and coach behaviour

Athletes are embedded in a broader system of sports organisations and healthcare systems that have direct and indirect influences on how concussions and injuries are managed (see online supplementary table S1). Among coaches, surveys reveal that most believe concussion education is important and have good general knowledge about concussions when tested about the likely symptoms.26 ,39 ,43 ,47 In general, coaches are more knowledgeable than parents.55 ,58

Surveys also suggest that coaches have misperceptions about medical evaluations used to treat and manage concussions,59 ,13 and do not consistently follow the proper procedures to return players to play.13 ,39 ,50 ,58 Recent studies demonstrated that 95% of coaches were familiar with state laws, but were less familiar with concussion consensus statements (only 65% reported familiarity with these guidelines).49 ,60 A consistent problem is that no standardised methods exist for training coaches, and the use of modalities to train coaches was extremely varied.6 ,60 ,61 Coaches reported that the most common sources of information included peers, coaching associations, conferences, the internet and printed literature.62 Finally, a common theme among surveys is that coaches have difficulty discriminating between concussion symptoms and non-concussion symptoms, and in implementing proper return to play guidelines.13 ,59 ,63

New Zealand introduced mandatory workshops to educate rugby coaches regarding the management of sports concussions. All participants were required to attend workshops, shown educational videos about the management of concussions and provided with training on the use of a side line concussion checklist. In the 2 years following the initiation of the programme, a significant reduction occurred in time taken for players to seek medical attention and significant economic cost savings were achieved based on medical claims. Results suggested the programme was highly successful in meeting objectives.64

Education informing clinicians’ approach to concussion management

ATCs continue to be a primary resource for athletes, as they serve on the ‘front lines’ of managing injured athletes. Initial surveys65 indicated that ATCs used a wide range of information primarily due to competing guidelines used to identify and manage concussions, but, overall, there was a trend for ATCs to use standardised methods. However, several years later, although ATC knowledge had improved considerably, most relied on clinical examinations and only 3% complied with the NATA 2004 position statement.32 ,66 Subsequent studies suggested that ATC knowledge had increased and the passage of the Lystedt law helped support concussion management.47 ,49 ,50 ,67 However, significant differences between urban and rural schools were noted, with the former showing a higher rate of compliance with international consensus guidelines. Current research suggests that ATCs continue to have difficulty differentiating concussion symptoms from non-concussion-related symptoms.13 ,68

Surveys among family physicians suggest that they rely on a wide range of educational materials, some of which are based on outdated information.69–71 As a result, there was considerable variation in treatment practices among those surveyed, with approximately 75% recommending physical rest but less than 30% recommending cognitive rest.71 Familiarity with international consensus guidelines was low, ranging from 15% to 50%, with over 25 different sources of concussion information being cited.69–72 Paediatricians and other specialists are generally well informed about sports concussion, but in several studies were less familiar with current concussion consensus guidelines,73 and Broshek et al70 found that only 36% of paediatric neurologists felt adequately trained. In contrast, most emergency medicine physicians utilised published guidelines.74 Other healthcare providers (eg, emergency nurse practitioners, paediatric nurse practitioners, family practice nurse practitioners) have similar gaps and misconceptions about knowledge of concussions, limited familiarity with national or international guidelines and provide varied treatment recommendations.69 Preferred methods of training among physicians included continuing medical education, e-learning activities and website resources supported by professional organisations.69–71 ,73 ,75

Training of medical students is limited, as a survey of Canadian medical schools found that only 29% provided concussion-specific education while 43% incorporated concussion education into medical school curricula.76 A survey among Canadian medical residents identified a high rate of misperceptions about concussion outcomes (for instance, chronic traumatic encephalopathy, second impact syndrome) but, comparatively, residents were more knowledgeable than medical students due to having more experience in working with concussions.75

Influence of legislation on education efforts

The implementation of state laws appears to have supported education efforts, although only a few studies have been published. In Washington state, the passing of the Lystedt law in 2009 has shown promise in improving knowledge among players, coaches and ATCs.6 ,61 Two studies that published outcomes within 2 years of the passing of the Lystedt law suggested that between 95% and 99% of coaches had received concussion education and 85% were familiar with state law.47 ,50 The wording of the legislation was vague, however, leaving the specifics of concussion education open to interpretation. As a result, a wide range in training methods was reported among coaches (some received literature while others had immersed training sessions), and differences were noted in concussion management strategies between rural and urban districts.6 ,50 ,61 Esquivel et al49 reported similar rates of familiarity with state law among coaches and athletic directors (95% of those surveyed were familiar) in Michigan, although educating players was not consistent across sports.

Contemporary education interventions

The objective evaluation of education efforts is limited (see online supplementary table S2). As noted above, surveys of coaches following the provision of the CDC's Heads Up toolkit were positive. O'Donoghue et al63 found higher knowledge among coaches who were trained within a classroom setting. Trends from the passing of state concussion laws have shown education has increased coach knowledge and use of concussion materials.6 ,49 ,50 ,59

Interventions with athletes

Surveys of preintervention/postintervention suggest short-term improvements following efforts to educate athletes while the long-term gains are mixed. Bramley et al found high school soccer players with previous concussion education were more likely to tell coaches and state that it was not okay to keep playing. Bagley et al77 found significant improvements among youth athletes immediately following a 40–60 min presentation using the Sports Legacy Institute for Community Education (SLICE) curriculum in a pre-test/post-test design, but long-term outcomes were not measured. Another study using a short, standardised 20 min presentation in a classroom setting found short-term (after the session) and long-term improvements (postseason) in college athlete knowledge.78 A pre-test/post-test assessment following a didactic lecture given to collegiate and professional football players found significant short-term increase in knowledge, although college players still had misconceptions about returning to play even after the lecture.78 Finally, the use of video gaming to educate athletes has shown promise, with a sample of youth hockey players reporting increased interest and knowledge gain, in a study by Goodman et al.79 However, the long-term impact of this knowledge gain is unknown.

A significant limitation when comparing outcomes from surveys is the varying item content that exists between studies. Although all studies in table 1 and supplementary table S1 used surveys that had established face validity (based on expert opinion and information from published guidelines), only one used a survey with published psychometric properties.12 This makes it difficult to generalise findings and draw conclusions from these studies. Furthermore, surveys have inherent methodological limitations in sampling behaviour and controlling for extraneous variables, and these factors significantly limit the ability to generalise findings. Although surveys suggest an overall trend of improved knowledge about concussions after education interventions, the evidence supported by sound methodologies is weak.

Among the few randomised controlled trials, results suggest positive trends in terms of improved knowledge, although evidence supporting these education interventions was mixed (see online supplementary table S2). In one study, 75 Peewee hockey players were randomly assigned to watch videos (Smart Hockey from the Think First Foundation) or to a control group. The experimental group showed improved knowledge about concussions compared with controls and the effect was maintained at 3 months.80 A larger sample of youth hockey players who watched the same video (Smart Hockey) at preseason also had improved hockey knowledge postintervention compared with controls, but the effect was not maintained 2 months later.81 The study also evaluated player outcomes during games, and while no significant change in penalty minutes was noted between groups, there was a trend for decreased body-checking infractions among the experimental group. A sample of older hockey players was randomly assigned to watch the Think First DVD (same as above), use an interactive computer module, or to be in a control group.45 The experimental groups showed a trend towards improved knowledge, although results did not reach statistical significance. Other studies included a sample of older adolescent hockey players who were randomly assigned to watch the CDC's concussion documentary, another documentary, or to be in a control group.14 Outcomes indicated that, 1 month later, no lasting changes were noted in player knowledge and, unfortunately, players were less likely to report symptoms.

Interventions based on theoretical models

The application of theoretical models has shown promise in better predicting attitudes regarding compliance to concussion guidelines and behavioural change from education efforts. For instance, the theory of planned behaviour (TPB) focuses on theoretical constructs that are concerned with individual motivational factors (ie, behavioural intention as determinants of the likelihood of performing a specific behaviour).10 ,14 ,82 ,83 Several cross-sectional studies that applied TPB to study high school athletes yielded similar findings, suggesting that attitudes were oriented towards under-reporting concussions, despite adequate knowledge of concussions.8–10

The introduction of safety and injury prevention in school curriculums was examined in a study by Gresham et al84 using Think First for Kids Injury Prevention curriculum addressing brain and spinal cord injuries. Children were taught six themes, one per week, and pedagogy included a wide range of methods including videos, role plays, comic strips, discussions and homework. A post-test identified significantly improved knowledge among nearly 2000 students in grades 1–3. A similar approach was used with 870 grades 1–3 students in Portland, Oregon, also using the Think First for Kids Injury Prevention curriculum. Post-test results were also significantly higher than pre-test surveys of injury prevention knowledge, with a greater effect for lower socioeconomic status schools.3 Other studies using an electronic module in a school health and physical education course among secondary students helped improve concussion knowledge in the short term.85 In contrast, a study of 545 upper elementary and high school students in Brazil, using a randomised control design, found no differences among groups at postevaluation, suggesting that multiple and different types of educational interventions did not modify attitudes towards injury.86

Interventions with coaches

Among coaches, Glang et al87 used an interactive video programme (ACTive e-learning) that consisted of three short modules lasting about 20 min, covering information about youth sports concussion, prevention, recognition and management. The programme used simple graphics and video segments with easy-to-follow navigational controls. Participants were randomly assigned to either the ACTive e-learning module or internet resources (control group). Results showed medium to large effect sizes with regard to concussion knowledge in the experimental group. Long-term retention of this information was not measured. The authors suggested that even short education sessions can improve coaches’ knowledge about sports concussion.59 ,63

Internet-based technologies

While many resources are available via the internet or on handheld applications, the evaluation of the effectiveness of these tools is limited (table 2). Ahmed et al41 published the only study applying the HONcode criterion to 43 common websites that provided education about concussions. Results found only a small proportion met criterion for acceptable content criterion and readability, while most showed evidence of missing or erroneous information. Reviews from Williamson et al37 highlighted several of the most helpful nationally recognised websites and the need for the presentation of consistent information for consumers. Other information presented in the media often depicts concussions in a humorous light, downplaying the seriousness of the injury.88 ,89 This can lead to stereotypes and misconceptions about the injury itself. Facebook and Twitter offer considerable potential for promoting knowledge about concussions,90 but there remains an important ethical responsibility in assuring proper information. Popular websites such as Youtube also may be employed to promote concussion education and knowledge.93 However, a recent review noted that only a few healthcare/sporting organisations have used Youtube as a viable source of information.11 ,90