by Dr. Eugene Bailey MD
There is currently a lot more known about concussions in sports than ever before. You don’t have to look far or very hard to find a list of concussion symptoms and the proper protocol in which to handle someone who has sustained a concussion. In fact, there are plenty of new rules in high school, college and even the professional ranks which provide guidelines regarding the handling of concussions.
All of this is good news and will hopefully lead to better safety and limit the number of young athletes who are sent back into practice or game. Doing so before they are healthy can cause a more severe second incident. However, these guidelines only apply when a concussion is reported and correctly diagnosed. And that is where there is still a big problem.
We have known for some time that athletes in sports such as football and hockey have failed to report symptoms associated with a possible concussion. It’s just part of the game, they might tell you. Getting a “ding” or your “bell rung” was something you would shake off and play through. They might also refer to a hit that shook them up as a “stinger.” Any significant head impact can cause a temporary loss of feeling making the athlete feel there was no injury. The problem is it takes more than feelings to know if a concussion occurred. A broad-based set of tests must be performed on every head impact, or a concussion can go unnoticed.
According to NATA and the Concussion in Sports Group, a sideline assessment should include; symptoms, cognitive, behavioral, balance and physical. A full sideline assessment need not take more than 5 minutes but offers a significant ability to screen for a potential concussion.
A couple of years ago, researchers from Harvard and Boston University surveyed 734 college football players from ten schools on:
- How often they’d been diagnosed with concussions,
- How often they suspected having concussions but didn’t get diagnosed,
- How often they suffered “dings” or “bell ringers” (slang for rattling blows to the head that may or may not cause concussions)1
It turned out that for every single concussion suffered over the course of these players’ careers, they also had four suspected — but unreported — concussions, and 19 so-called “dings.” And other data collected, on symptoms experienced by players, suggests that many of these “dings” were, in fact, concussions.
In other words, if these numbers are accurate, more than 80 percent of concussions don’t even get officially counted.
The data in the survey comes from players at ten schools in the NCAA’s Football Championship Subdivision, which is one level just below big-time Division I football. Players were asked the number of concussions they’d had over the course of their careers so far, the number of times they suspected having concussions but didn’t get them diagnosed, and the number of times they got a “ding” or had their “bell rung.”
The results proved to be even worse than previous estimates for unreported concussions. Of the 734 players surveyed, here are the results of the three fundamental questions asked.
- “How many times have you been diagnosed with a concussion by a medical professional (doctor, athletic trainer, nurse)?2”
- The average response rate was 0.64 times
- “How many times have you sustained an impact that you suspect was a concussion but that was never diagnosed?”
- The average response rate was 2.64 times
- “How many times did you get a ding or get your bell rung?”
- The average response was 12.32 times
As can be seen, by the results, many more occurrences of possible concussions are never reported or diagnosed, up to 80% which is an alarming and troubling number.
The study also looked at which football position groups were most affected. It turned out that offensive and defensive lineman are at the top of the list. Although their impacts are at lower speeds, there is contact on nearly every play, and it’s thought that their symptoms may even be due to the cumulative effect of all of the hits during seasons of playing the game. Also, a lineman is less noticeable, and many times these players tend to play through the injury rather than exiting the game.
Many of the reasons athletes don’t report symptoms of a concussion are relatively obvious. Most of them have to do with the attitude and toughness related to the game they play. Some of the primary reasons are;
- Not wanting to leave a practice or a game because of the fear of looking weak to either your teammates, coaches or parents.
- The fear of letting the team down by not playing through your symptoms and possibly costing your team a chance to win a game.
- The possibility of losing your spot in the lineup by not playing.
- Proving to everyone that you are tough and can get up from a hard hit and show that it doesn’t bother you.
- Concerned that by not playing you could lose the opportunity for a scholarship or even a professional contract.
As previously mentioned, many leagues now have specific concussion protocols in place. These include keeping players away from the field until all symptoms are gone and also fines in some instances when the protocol is not followed. Unfortunately, it appears that players and even teams are “hiding” the symptoms of a concussion to avoid the rules and penalties at the expense of team goals.
Even with all of the new information regarding concussions and their symptoms, do players believe they have been hurt enough to report it to team trainers or coaches?
According to an Indiana State University study3, that lack of knowledge could be putting athletes at risk for more severe injury, or even death, researchers say.
“When your head is messed up, you may not know it yourself,” said JoEllen Sefton, a doctoral fellow in sports medicine who surveyed 457 players, 38 coaches and eight trainers from eight NCAA Division I-A, I-AA and II colleges.
Coaches, players, athletic administrators and medical personnel have long known the risks of injury to the brain. But Sefton’s survey as far back as 2002, indicates nearly three of every four concussions go unreported.
The Indiana State study, published in the Journal of Athletic Training, gave players a list of symptoms and asked them to identify which were associated with concussions and which were not. It asked players how many of those symptoms they had experienced, and how often they had reported them, after a hit to the head.
Sefton said those surveyed suffered symptoms consistent with concussion 391 times — 21 percent of them more than once. But 72 percent of the symptoms were not reported, primarily because the athlete did not think the injury was severe, she said.
So how can the athletic community change when it comes to the reporting of possible brain injuries? It’s likely not an easy question to answer. Players are still going to want to play through injuries and show their toughness. And many have, and at all cost mentality. The pressure on players to perform for their parents, teams, scholarships or professional dollars is not going to lessen, although it should.
Some of the new protocols and rules in sports are a step in the right direction. Continuing to implement and enforce concussion awareness has to be a priority to get a handle on treating the athlete and helping them get better before playing again.
But the answer comes down to safety for the athlete with any preventative measures such as rules or equipment changes. And knowing it’s alright to let someone find out when they think they have sustained a head injury.
Players need to be comfortable that there won’t be any repercussions, other than their safety, by telling a coach or trainer that they have suffered an injury. It may not seem like much, a headache, some dizziness or temporary mental confusion, but no symptom should be ignored.
Particularly in sports higher in physical contacts such as football, hockey, and soccer, education is the key to getting players to buy in. The next step may be making sure everyone involved is educated regarding the dangers and signs and symptoms of a concussion. These include the players, coaches, parents, trainers and even the officials. Parents are especially important since they influence their child that others don’t. Parents telling them they should feel comfortable reporting their symptoms can be a big step.
And coaches, whether in youth, high school, college or professional sports, will need to prioritize safety above all else before we see the percentage of unreported concussions change. It’s a cultural shift, and it won’t be easy. Once players know that it’s okay to report their injury, not just with coaches but with parents as well as their peers, we should see an improvement in this area. That, combined with advances in rules and equipment, will be the driving forces behind increasing safety for athletes regarding concussions.