Introduction
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.
Conclusion
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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