Sunday, May 5, 2013

Promoting Sports Concussion Awareness to Minimize Long-Term Consequences: A Critique Based on Health Promotion Theory - Jacqueline Byrd

Pediatric traumatic brain injury (mTBI) has an estimated annual incidence of 180 cases per 100,000, and accounts for over 400,000 hospital visits each year.  Eighty to ninety percent of all TBI cases are considered to be mild TBI (MTBI).  In fact, it is believed that even more cases of MTBI go unreported.  While many deficits resulting from MTBI have resolved 2-3 months post-injury, there are studies indicating that a sizeable minority of patients are experiencing persistent problems following their injury (1). Of the TBIs that are accompanied by loss of consciousness, twenty percent occur in sports – indicating a need to address the delivery of care not just in emergency departments, but on the field (2).  While these injuries may be classified as “mild,” they still pose a risk of long-lasting effects on pediatric patients if they are ineffectively and improperly diagnosed and managed.  In fact, due to patient perception of the injury’s true severity, the experts in the field use the term “concussion” to refer to mild traumatic brain injury (3).
Athletes are at increased risk of concussions due to the acceleration/deceleration nature of the injury.  As the damage of a concussion is restrained within the skull, no protective equipment is effective.  The majority of concussions occur outside of sports (in motor vehicle accidents, falls, abuse, etc), but contact sports and even cheerleading pose higher risks of falls and hard hits than non-sports activities (2).  The deleterious long-term consequences of concussion appear to be linked to repeat concussions, so tracking the occurrence of a concussion and the injury mechanism is vital.  While preventing all concussions may not be possible, risk of second impact syndrome and chronic traumatic encephalopathy can be reduced by empowering athletes to speak up if they suspect a concussion, adhering to return to play guidelines, and considering changes to youth sport rules.

Current approach: imPACT, Heads Up and Concussion Laws
The most popular practice targeted at concussion in high school sports is baseline computerized cognitive assessment for student athletes.  This testing was used in 41.5% of all concussion cases reported, representing a rapid increase from the previous academic year (3). While athletes are at a higher risk of concussion, and repeat concussion, there is no equivalent (either in education or baseline cognitive assessment) for non-sports related concussions. This expensive practice needs more follow-up testing as there is not data to indicate this reduces the risks of returning to play too soon (1). It is important to note that this intervention is focused on the risk of repeat concussions and even then, can only identify a concussion if a baseline has been established.  This is not a one-time diagnostic test for concussion.  This testing typically occurs once or twice a season, as sideline assessment is expected for in-play injuries.  If a concussion is suspected or diagnosed, an athlete must wait until medically cleared to return to play.  This can mean missing championship games, scouting visits or simply time with the team.  There are varying guidelines about rest after sports-related concussion before return to play. The decision must be made carefully due to risk of second-impact syndrome (3).  However, there is still not adequate evidence to determine the exact time to wait, so most physicians err on the side of caution.
Most states have specific concussion laws regulating coaches’ concussion training and response to concussions.  These laws exist separately from the school systems’ adoption of baseline testing, as few of these laws mandate baseline testing.  These laws have evolved from the media attention that concussions in professional sports have gained over the past few years (3).  Concussion laws require training for coaches and require that coaches follow return to play guidelines.  These laws do not specify which guideline coaches should follow, nor do they provide financial resources for training of coaching staff and school staff.  Most educational programs to satisfy the law are online trainings, like the Center for Disease Control and Prevention’s “Heads Up” initiative.  Launched in 2005, “Heads Up: Concussion in High School Sports” initiative provides materials and multimedia presentations online for coaches.  More recently, the CDC launched “Heads Up to Schools: Know Your Concussion ABCs” for grades K-12 school personnel (4).
No current intervention addresses the complex environment shaping youth athletes’ decision making around the issue of concussion.  Unlike other prevention issues, concussion prevention is complex and cannot be accomplished through any single change or use of a piece of protection equipment.  Concussion education should encompass prevention and response and must account for barriers – financial, cultural and structural – to implementing recommended practices.  An effective intervention should work with individual young athletes, but must work to change the sports culture in the US to be more safety-conscious.

Criticism of Intervention 1: Legislation creates a burden, not a behavioral change
Thirty one states have a concussion law in place that requires a form of education for athletes, coaches, parents, educators or some combination of the four key groups (10).  Specific education programs are not created or recommended by concussion laws, nor do the laws create specific guidelines to follow.  Most coaches have turned to the Center for Disease Control and Prevention’s “Heads Up” program and report that they view the CDC as a credible expert on the issue.  However, as Chris Nowinski, former professional wrestler and co-founder of the Sports Legacy Institute, observes, “stuff's been online for five years.  The problem is nobody goes and does it unless they're required to. And everybody in the industry knows that" (9).  The concussion laws require education, which is satisfied by the CDC’s course in most states.  However, evaluation of the success of these courses has been limited to small studies.   These small studies have found improvements in coaches’ self-reported awareness of the risk and severity of concussions (4).  However, requiring training that also mandates specific actions in response to a concussion may backfire if coaches feel, as youth do, that “they [do] not want to be told what to do” (11).
As a consequence, most Massachusetts coaches and families felt a burden from the requirements of the law rather than encouraged at the attention the issue was receiving.  Evaluation of concussion laws and the educational programs that satisfy them finds an increased awareness of the severity of the issue, but these evaluations have not been able to examine changes in behavior (12). The scope of each concussion law varies state to state, but these laws impose financial burdens on youth athletics programs and schools that need to put a doctor on every sideline.  The national attention the NFL, and former NFL players, is garnering at the national level is also drawing legislator’s attention to the possibility of a national concussion law. 
These state laws are not transferrable without consideration of resources and geography.  Furthermore, requiring parents and coaches take action ignore the extraordinary control the player has in this arena.  Laws require that adults in positions of supervision remove athletes suspected of a concussion from play and follow one of several return to play guidelines.  If the law required removing every player with a knee injury, coaches and parents could spot the injury without requiring any input from the athlete.  Unfortunately, the “unseen” nature of concussions requires that recognition of the injury is up to the player.   The director of the the Chicago Neuropsychology Group commented in the Chicago Tribune, "We only have as much power as an athlete is willing to tell us" (9).  Legislation helps engage parents and coaches, but behavioral change has to start with the athletes as the focus of this legislation ignores the power the athletes wield over disclosing concussions.

Criticism of Intervention 2: Interpersonal - Interventions ignore social norms          
Education and public awareness are crucial components of any intervention addressing sports concussions.  Providers often dismiss the severity of a concussion as post-concussive symptoms resolve with 1-2 weeks of injury in most individuals (1). Even providers who try to stay on top of the latest guidelines are at a disadvantage as guidelines for pediatric population, especially in sports-related concussions, lag behind adult TBI due to lack of data for evidence-based conclusions.  Despite insufficient data, more is known now than a generation ago, but the underlying beliefs of providers (as well as those of the general public and the youth sports community) can complicate diagnosis and management. This confusion can extend to a difficulty recognizing subtle, long-term cognitive signs of post-concussive syndrome. Unfortunately, this belief in the minor and transient nature of the injury also exists among providers who may more readily dismiss concerns from patients because “it’s just a concussion.” Pediatricians and emergency department physicians are not always aware of latest brain injury management guidelines (3).  
            An evaluation of the CDC “Heads Up” concussion initiative for high school coaches found that coaches and parents underestimated the potential risks of concussions (4).  The idea of a “bell ringer” or other harmless hit is entrenched in football and hockey culture, and is consistent with the sports’ aggressive culture where hard hits are rewarded.  An analysis of Canadian and American newspaper coverage of brain injuries in ice hockey found that where papers once only reported injuries to star players, they are now reporting those injuries in the context of the larger issue.  This represents an improvement in the media’s focus on the issue.  Unfortunately, the previous media coverage and the conflicting views of fans and athletes create confusion in the public.  Even as injuries to star and unknown players are reported, there is still a public perception that these injuries are “just a part of the game.” The conflict between this perception and what the papers are reporting could reduce the impact of these media messages about harmful brain injuries. (5).
The culture at the amateur and professional levels of these contact sports has created a social norm where athletes expect to get hit and do not want to show weakness by withdrawing from play – they want to win the game at any cost (5).  This norm influences the behavioral intention of young athletes according to the Theory of Planned Behavior (6).  Injuries are so expected in playing the sport that star professional athletes are remembered for playing through injury.  As a result of this social norm, a young athlete may believe that his peers and coaches would disapprove of letting a suspected concussion end his game.  This is considered an injunctive norm, the perception of what is approved or disapproved, within, in this case, sports team culture.  Injunctive norms are especially important to address as they can mediate the boomerang effect of promoting the descriptive norm, the prevalence of a behavior, in a society (7). 
Aside from teammates, other individuals whose approval is important to young athletes are their parents.  While some concerned parents were involved in the advocacy efforts for the Massachusetts Concussion Law, all parents are reliant on coaches and the media for information about concussions in sports.   The terminology is confusing; some parents think a “concussion” is distinct from a brain injury (8). Public perception was once that a second blow to the head could cause the return of things forgotten in the first blow to the head.  As many parents of young athletes were once young athletes themselves, they think their children are fine playing the sports the way they played them.  As we know now more about the risks of repeat concussions, it is important that the overall attitude about youth sports change.  This will require targeted education efforts to key groups involved – on and off the sidelines.

Criticism of Intervention 3: Intrapersonal - The Intervention is Ineffective at Changing Individual Knowledge and Attitude

Existing interventions have either focused on athletes or coaches, but have not appropriately incorporated behavioral theory to these and never expanded to other key members of the community. “Heads Up” posts education videos directed at coaches online for others to view, but they videos are coach-specific.  While some interested parents and providers may seek these videos out, there are currently no interventions targeted at them on a large scale.  This is significant as pediatricians (rather than athletic trainers) see the majority of pediatric athletes with concussions; without proper training and education, many of these physicians lack the tools to assess and manage concussions (1). Medical management of concussions may not prevent their occurrence, but it can mediate long-term effects; provider education cannot be overlooked in any comprehensive concussion care model.
Concussion education for athletes and their supervising parents initially focused on addressing the Health Belief Model by increasing perceived severity and perceived susceptibility. However, as it has expanded to try to address the culture of youth sports, the Theory of Reasoned Action has been applied to include social influence (6). This theory suggests that education about concussion also runs the risk of the boomerang effect. Education that provides information on descriptive norms, whether the prevalence of concussions, the (low) prevalence of lasting consequences from a single concussion or the number of athletes suspected of not reporting concussions, can provide the level from which an athlete does not want to deviate (7).  If an athlete has not yet had a single concussion, but learns how many others have, he may take more risks if he sees concussions as the standard in sports.  Legislation that requires coaches or athletes – or both – to undergo education can backfire if social and behavioral theory is not first applied to the development of educational interventions.  
Individual interventions targeted at athletes must remain a key technique of the health promotion model targeted at preventing and responding to athletes.  These education efforts must be carefully constructed.  The current model focuses primary on how to recognize and respond to a concussion.  This intervention is framed as a response effort and not a prevention effort, leading to the impression that any intervention to prevent concussions is futile (15).  Even if athletes are convinced, in accordance with the Health Belief Model, that they are susceptible to a serious harm, they may not change their behavior if they believe that susceptibility is unavoidable.
One non-health deterrent for athletes reporting concussions is the consequences such reporting could have on their fledging athletic career.  Experts recommend “retiring” from the sport, even at the high school level, when a concussion can be obtained with decreasing force.  Players realize that each reported concussion could be another step towards the end of a career – and the loss of any chance at scholarships or endorsements.  For instance, heading a soccer ball should not produce a concussion. If it does, that soccer player’s physician should recommend ceasing involvement in the sport. That player, regardless of talent, could never obtain the rewards that so many young athletes (and parents of young athletes) hope for. 

Proposed Intervention: Use Athletes to Educate the Public, Empower Young Athletes, and Change the Social Norms of Youth Sports
Legislation should be a component of all state’s interventions and it demonstrates widespread commitment to the issue, but it cannot effect behavioral change in isolation.  Advocates for legislation must also transmit their passion for reducing concussions in youth sports to state and local education and awareness programs for all key individuals in youth sports.  Training can be required for athletes and school employees – coaches, teachers and administrators –  but it can only be made available for parents, doctors and the general public.  Just as legislation cannot independently change behavior or culture, neither can education alone make all the difference in injury prevention.  The strong advocacy network that compelled legislators to act needs to evaluate what can compel young athletes to act. 
 These activated parents and coaches need to focus not just on changing the laws at the state level, but on changing the rules and regulations of youth sports.  This normative shift will come gradually, but will be possible through the involvement of parents and athletes in education directed at fellow parents and athletes.  Utilizing in-person events at schools and competitions in conjunction with an active presence on social media and online video-chat programs (Skype and Google Hangout), professional athletes who have made the decision to sit out a game will share their thought process with young athletes.  This gives young athletes to ask professional athletes about the consequences on their careers and whether they would do it again.  A network of young athletes, mentored by these professional athletes, will be established.  This will create an opportunity for peer education.  These young athletes will share the stories they hear from professional athletes with their teammates.  Coaches and parents will help facilitate this peer education system and will publicly recognize young athletes with concussions who identify their suspected injury at the moment it happens. 
As more and more youth athletes, teams, and youth athletic associations see the benefits of caution in youth sports, they will be empowered to slowly institute changes in the structure of youth sports.  This will be a form a passive protection, which will go hand in hand with active prevention efforts as part of the Health Promotion Framework. The successful stories of professional athletes who abided by return to play guidelines and are continuing to compete will contrast sharply with the serious issues in other athletes who sustained repeat concussions in quick succession.  The prior attempts at public awareness have veered towards a fear campaign with the risks of chronic traumatic encephalopathy; this intervention will work within the positive culture of youth sports to encourage teaching precaution as well as teamwork.
Defense 1: Provides effective intervention support to the legislation
Concussions will never result in the obvious symbols of sports injury – casts, crutches, or slings – but their effects can be more long-lasting and life-altering.  Recognition of the problem at the legislative level is a victory for concussion advocates, however there is still a lot of work to be done to change the public perception of concussion and the role of youth sports in minimizing them.  Public awareness and education efforts are critical as parents need to learn about the risks of sports injuries even before they have children.  President Obama recently commented that he would have to think long and hard before letting a son play football.  In the same interview, he expressed an understanding that the sport would have to change (16).  He, along with many other parents, may be prepared to see action taken, but they may resist regulation changes they are not a part of. 
The best advisors for an education effort in hopes of championing changes to youth sports are future and current parents themselves.  In fact, the Principle of Participation suggests that parents’ behavior change will be greatest if they are involved in planning the intervention planning.  Parents are put at risk by youth concussions as well as the child, so they should also be engaged in the effort.  Rather than doctors suggesting changes to youth sports, the experts should engage parents on what concerns and suggestions they have.  This is in accord with the Principle of Relevance which argues that change is the greatest with the organizers of the change effort engage the community members at risk (15).
            This proposed intervention does not rely on single individual-level theories, but instead acknowledges the need for changes to behavior and environment, as examined through the Health Promotion Framework (15).  If the sports and the way they are played (e.g., tackle football at a young age) are contributing to the high rate of concussions and trend of multiple concussions, then more than just individual behavior needs to change.  This proposal aims to educate all involved stakeholders so that they are equipped to change youth sports.

Defense 2: Increases awareness of youth sports culture and motivates changes to norms

Concussions can be prevented through modifications to youth sports practices, however, such a structural change must begin with individual behavioral changes.  Intrapersonal interventions are the first component of an active strategy to encourage behavioral change.  All young athletes are in the pre-contemplation phase of the Transtheoretical Model where they need to be aware of the need to act differently than they are used to when it comes to concussion.  The goal of a comprehensive intervention is to provide young athletes with enough age-specific information and advice that they are prepared to take action when the time comes.  The action of reporting a concussion to a coach is only possible after sustaining a concussion, so rather than cycling through the Stages of Change at their own pace, athletes wait in the precontemplation-preparation steps until sustaining a hard hit (17). 
Educating young athletes about the odds of concussions over their careers and the dangers of concussions increases their awareness of the need to change their response to concussion.  Teaching athletes about their susceptibility to harm and the need to support their team mate’s decisions to protect their brains integrates principles of the Health Belief Model and the Theory of Planned Behavior within the timeline of the Transtheoretical model.  If they have heard professional athletes describe the signs of a concussion in play and the risks of playing with a concussion, these young athletes will be motivated to decide on action plans in the event of a concussion.  Ideally, this action will entail communicating their injury to their coaches immediately.  Young athletes who have sustained concussions will also be valuable additions to the peer education program.
In fact, these injured young athletes are one example of an effective communicator to lead the necessary educational efforts.  Sports culture is created by the stories of perseverance and physical performance in the media about famous college and professional athletes.  Young athletes aspire to this level of competition, where aggression and playing through injury is rewarded by the fans, media and teammates.  Only recently have athletes come forward to reveal suspected concussions that led them to remove themselves from competition.  The media must continue to highlight these stories, as examples of role models prioritizing their own cognitive health over a sports competition.  If this intervention hopes to communicate the message that young athletes should immediately disclose a suspected concussion to adults, the communicators must be carefully chosen. 
Concussion prevention messages are typically delivered by coaches and doctors.  However, these messages should be delivered by fellow young athletes who sustained a lasting injury or professional athletes who sat out a game due to a suspected concussion.  Reactance theory suggests that attraction to the communicator increases the positive force towards similarity.  A credible athlete can also undermine resistance as these athletes made their decisions despite the same team-oriented competitive point of view (14).  Coaches can be trained to recognize the signs, but athletes are more likely to respond to a fellow athlete’s advice about action to take with a concussion than their coach – especially if their coach was not an athlete.
Most professional athletes played youth sports, just as many parents involved in their children’s sports did.  A few professional athletes have come forward to discuss their decision to stay on the sideline with a concussion.  In one case, one of the most famous NASCAR drivers stayed out of a race after sustaining a concussion in a prior race crash.  Dale Earnhart Jr.’s own words demonstrate that it is not an easy choice, but that he feels better for having made it: "I feel fortunate to have recovered from this concussion quickly, and I feel lucky I made the choices I did. Had I tried to push through it like I did the other ones I was putting myself in a lot of danger” (18).  It is these athletes who have the most power to wield in communicating the message of reforming youth sports. 
They acknowledge that the decision is hard and leaves them yearning to be in the competition, but demonstrate that they value their long term mental health over any single competition.  These athletes demonstrate that the perceived benefits outweigh the perceived costs even at the highest levels of competition.  Their public statements, even if they would rather compete than serve as a spokesperson for an issue, go a long way in serving as a cue to action for younger athletes. In addition to meeting the health motivation constructs of the Health Belief Model, the involvement of these athletes changes the norms of sports competition.  If athletes are sitting out of competition because of a bad crash or hard hit, they are demonstrating that continuing to compete is not acceptable.   

Defense 3: Education of athletes and parents improves self-efficacy
Equipped with a role in evaluating the danger of youth sports and aware that their children are being mentored on how to avoid and recognize concussions, parents of younger athletes will feel they have more control over their behavior in regards to concussions.  Similarly, recognizing young players who independently chose to report a concussion will demonstrate to other players that every player is in control of his own behavior.  The Theory of Planned Behavior adds perceived behavioral control to the Theory of Rational Action, which was previously discussed with regard to norms (17).  While coaches should be educated on proper protocol, especially for head injuries requiring immediate medical intervention beyond sideline cognitive assessment, athletes should feel empowered to remove themselves from a game as a precaution if they suspect a concussion.  Accomplishing this requires both changing athlete’s attitudes about concussions and improving communication between coaches, parents, athletes and doctors about the appropriate steps to take. 
Athletes who report a suspected concussion (whether it happened on or off the field) should be used by coaches as a positive example.  Publicly recognizing these athletes will help other athletes realize that their own decisions are in their control and will be approved by their coach and teammates (15).  Athletes need to feel a high degree of control of their ability to recognize a concussion and remove themselves from play.  As the proposed intervention aims to ultimately reform youth sports, these athletes also need to have a sense of control over their behavior in the sport. Every professional athlete who has gone public with his or her own concussion should be connected with young athletes.  It is especially important for professional athletes to recall concussions earlier in their careers and for high school athletes who have sustained concussions to share their own experiences.  The use of professional and young athletes as communicators will reduce resistance, while the messages they share will not only promote compliance but empower young athletes to take action to change their sports.

Reducing sports concussions requires more than one intervention.  The approach must be multi-faceted and must engage the stakeholders.  While education should be age-specific, young athletes should be brought into discussions about potential interventions and should contribute to curricula.  Establishing a program to connect young athletes with professional athletes will create an initial effective communication that can be extended further through a system of peer education.   Applying the Ecological Model and Health Promotion Framework in addition to individual-level theories, highlights the need to create active and passive changes, in behavior and structure, respectively.


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