APPLIED NEUROPSYCHOLOGY: ADULT, 22: 108–113, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 2327-9095 print=2327-9109 online DOI: 10.1080/23279095.2013.860604
Limited Knowledge of Concussion Symptoms in College Athletes Andrew Fedor and John Gunstad Department of Psychology, Kent State University, Kent, Ohio
Concussions are common in athletes and often go unreported. A likely contributor to underreporting of concussions in athletes is lack of knowledge of concussion-related symptoms. The current study assessed concussion symptom knowledge in 382 Division I athletes and 230 nonathletes. Participants were asked to identify potential symptoms following a concussion from a list of both real symptoms and distractors. Studentathletes expected significantly more total symptoms following a concussion than did nonathletes, and they correctly identified symptoms such as nausea and=or vomiting and being easily upset by loud noises more frequently than controls. However, many student-athletes failed to identify possible emotional symptoms resulting from a concussion, and approximately 70% of student-athletes endorsed the distracter item ‘‘forgetting names or faces of people you know well’’ as being a symptom of concussion. These current findings suggest that student-athletes may have an incomplete understanding of concussion-related symptoms, and future studies are needed to determine whether formal education sessions can improve knowledge for this high-risk population.
Key words:
amnesia, athletes, college, concussion, knowledge
An estimated 1.6 million to 3.8 million sport-related concussions occur each year in the United States (Langlois, Rutland-Brown, & Wald, 2006). Observable symptoms such as loss of consciousness, disorientation, or reduced motor coordination (Meehan & Bachur, 2009) facilitate accurate and timely diagnosis of concussion. However, many concussion-related symptoms are subjective and self-report remains an important aspect of concussion diagnosis (Notebaert & Guskiewicz, 2005). For example, headache, dizziness, and increased fatigue are common after a concussion and comprise an important part of a concussion diagnosis (McCrory et al., 2009). Incomplete knowledge of concussion symptoms in athletes could complicate diagnosis and place individuals at risk for injury. For example, less than one in five concussed football players recognized they had Address correspondence to John Gunstad, Department of Psychology, Kent State University, 221 Kent Hall, Kent, OH 44242. E-mail: [email protected]
experienced a concussion (Delaney, Lacroix, Leclerc, & Johnston, 2002), and 20% of football players later diagnosed with concussion returned to play because symptoms were not identified until after the game (Delaney, Lacroix, Leclerc, & Johnston, 2000; Guskiewicz, Weaver, Padua, & Garrett, 2000). Kaut, DePompei, Kerr, and Congeni (2003) found that more than half of collegiate athletes did fully not understand the symptoms associated with concussion, although a majority identified a basic awareness of physical (e.g., loss of consciousness) and cognitive (e.g., memory problems) symptoms postinjury. Other research has shown football players to be more knowledgeable about the symptoms of concussion compared with controls (Simonds, 2004). However, this same research also revealed that football players are more likely to believe it is acceptable to continue play despite concussion symptoms such as confusion or pain. This latter finding may suggest football players are less knowledgeable about the long-term consequences of concussion (Simonds, 2004). This pattern is consistent with the incomplete knowledge of concussion symptoms found in many
CONCUSSION KNOWLEDGE IN ATHLETES
coaches (Mrazik, Bawani, & Krol, 2011; Valovich McLeod, Schwartz, & Bay, 2007) and the tendency of some coaches to downplay concussion severity (Buzzini & Guskiewicz, 2006). The current study sought to examine differences in concussion symptom knowledge between athletes and controls. Based on these data, we hypothesized that many student-athletes would have an incomplete understanding of concussion symptoms.
METHODS Participants Data were collected from 382 National Collegiate Athletic Association Division I athletes (228 men, 154 women) at a midsized Midwestern public university. Athletes ranged in age from 18 to 24 years old (Mage ¼ 19.57 1.24 years). Average years of playing experience at the collegiate level were 1.69 years (1.59 years). Separately, data from 230 college students (77 men, 153 women) not involved in collegiate sports were collected from this same Midwestern public university to serve as a control group. Control-group participants ranged in age from 18 to 27 years with an average age of 19.56 years (1.75 years). Measures Risk Perception Questionnaire (Appendix). The Risk Perception Questionnaire (RPQ) includes a checklist of 16 potential symptoms following concussion. This checklist was developed for the current study using items from the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Revision (American Psychiatric Association, 2000) that are commonly associated with concussion. Specifically, the RPQ checklist includes four distractor items (i.e., relationship problems, excessive sweating, seeing or hearing things that are not there, and forgetting names or faces of people you know well) not related to concussion symptomatology that can be used to help determine accuracy of expected symptoms. The symptoms that comprise the RPQ are generally similar to those found in the Postconcussion Symptom Scale (PCSS; McLeod & Leach, 2012; Pardini et al., 2004), with two key differences. The PCSS contains no distractor items, though it specifies directionality of symptoms (e.g., sleeping more=less than usual rather than any sleep disturbance). A composite variable was created that reflected the total number of symptoms endorsed on the RPQ, including any possible distractor items. The RPQ demonstrated adequate internal consistency in this
109
sample with a Cronbach’s a .74. Additionally, correlations between individual items and the total score ranged from a low of r ¼ .38 (headaches) to a high of r ¼ .56 (feeling depressed). Distractor items were retained for analyses to help discriminate levels of knowledge between student-athletes and controls. Immediate Postconcussion Assessment and Cognitive Testing. The Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) is a computerized neuropsychological test battery designed to collect demographic=medical data and quantify cognitive function in several domains (Lovell, 2007). The current study used only the self-report information from the ImPACT. Procedure Data were collected under different conditions for student-athletes and controls. All student-athletes completed all study measures as part of baseline preseason testing for their respective sport. These broad evaluations are conducted by a team of experts with backgrounds in medicine, athletic training, and neuropsychology. Most relevant to the current study, student-athletes presented for concussion-related measures in groups of approximately 15 individuals. They were then placed into separate exam rooms to complete the RPQ and ImPACT. To avoid possible inflation of symptom report and=or demand characteristics (Edmed & Sullivan, 2012), the RPQ was administered before the ImPACT. The number of concussions was obtained through self-report from the athletes during this evaluation and was verified by athletic training staff, though no severity information was available for the current study beyond athletes missing at least one practice. Undergraduate controls completed the RPQ and provided basic demographic=medical information during individual testing sessions. Unlike the student-athletes, controls did not complete the ImPACT and did not receive one-on-one supervision during completion of study measures. Controls received research course credit for their participation. Data Analysis A series of analyses examined differences in concussion knowledge between student-athletes and controls. First, t tests were used to examine the total number of expected concussion symptoms between student-athletes and controls, and then these results were clarified through t tests on each subtype of concussion symptoms (i.e., distractor, somatic, cognitive, emotional, sleep). For these analyses, group membership (i.e., student-athlete vs. controls)
110
FEDOR & GUNSTAD
served as the dependent variable with the individual symptoms being the independent variable. Chi-square analyses were then used to investigate possible differences in endorsement rates of specific symptoms between student-athletes and controls. Finally, analysis of variance (ANOVA) was used to examine whether student-athletes across various sports expected different numbers of symptoms following a concussion compared with controls. For this analysis, the independent variable was group membership (i.e., individual sport played vs. control), while the total number of expected concussion symptoms served as the dependent variable. As multiple comparisons were performed, a Bonferonni adjustment was applied to reduce the risk for possible Type I error.
RESULTS Student-Athletes Differ From Controls on Concussion Symptom Knowledge T tests showed student-athletes (M ¼ 11.15 4.06 symptoms) expect significantly more symptoms following concussion compared with controls (M ¼ 9.64 4.37 symptoms), t ¼ 4.33, p < .001. T tests revealed student athletes expected significantly more distractor (1.19 1.05 vs. 0.84 0.89), somatic (6.05 1.76 vs. 5.30 2.12), and cognitive (2.31 0.90 vs. 2.01 1.10) symptoms compared with controls. No significant differences emerged for emotional or sleep symptoms. See Table 1. Chi-square analyses revealed that student-athletes were more likely than controls to endorse the likely presence of a number of symptoms following a concussion, including nausea and=or vomiting, sleep disturbance, and forgetfulness or poor memory. See Table 2. Examination of specific symptoms revealed that many student-athletes expected to experience headaches (94.8%), dizziness (90.3%), and nausea and=or vomiting (77.5%) after suffering a concussion. However, 70.4% of student-athletes also endorsed the distractor item
TABLE 2 Patterns of Symptom Endorsement Between Student-Athletes and Controls
Symptom Distractor Symptoms Forgetting names or faces of people you know well Relationship problems Excessive sweating Seeing or hearing things that are not there Somatic Symptoms Headaches Feelings of dizziness Nausea and=or vomiting Easily upset by loud noises Tiring more easily Blurred vision Easily upset by bright light Double vision Emotional Symptoms Being irritable, easily angered Feeling depressed Feeling frustrated or impatient Cognitive Symptoms Forgetfulness, poor memory Poor concentration Taking longer to think Sleep Symptoms Sleep disturbance Restlessness
Student-Athletes
Controls
% Endorsing Yes
% Endorsing Yes
70.4
49.1
10.5
8.3
0.81
.37
15.4 22.5
10 17.0
3.67 2.73
.06 .09
94.8 90.3 77.5
91.7 89.1 68.7
2.20 0.22 5.79
.14 .64 .01
61.5
43.0
19.77
Limited Knowledge of Concussion Symptoms in College Athletes Andrew Fedor and John Gunstad Department of Psychology, Kent State University, Kent, Ohio
Concussions are common in athletes and often go unreported. A likely contributor to underreporting of concussions in athletes is lack of knowledge of concussion-related symptoms. The current study assessed concussion symptom knowledge in 382 Division I athletes and 230 nonathletes. Participants were asked to identify potential symptoms following a concussion from a list of both real symptoms and distractors. Studentathletes expected significantly more total symptoms following a concussion than did nonathletes, and they correctly identified symptoms such as nausea and=or vomiting and being easily upset by loud noises more frequently than controls. However, many student-athletes failed to identify possible emotional symptoms resulting from a concussion, and approximately 70% of student-athletes endorsed the distracter item ‘‘forgetting names or faces of people you know well’’ as being a symptom of concussion. These current findings suggest that student-athletes may have an incomplete understanding of concussion-related symptoms, and future studies are needed to determine whether formal education sessions can improve knowledge for this high-risk population.
Key words:
amnesia, athletes, college, concussion, knowledge
An estimated 1.6 million to 3.8 million sport-related concussions occur each year in the United States (Langlois, Rutland-Brown, & Wald, 2006). Observable symptoms such as loss of consciousness, disorientation, or reduced motor coordination (Meehan & Bachur, 2009) facilitate accurate and timely diagnosis of concussion. However, many concussion-related symptoms are subjective and self-report remains an important aspect of concussion diagnosis (Notebaert & Guskiewicz, 2005). For example, headache, dizziness, and increased fatigue are common after a concussion and comprise an important part of a concussion diagnosis (McCrory et al., 2009). Incomplete knowledge of concussion symptoms in athletes could complicate diagnosis and place individuals at risk for injury. For example, less than one in five concussed football players recognized they had Address correspondence to John Gunstad, Department of Psychology, Kent State University, 221 Kent Hall, Kent, OH 44242. E-mail: [email protected]
experienced a concussion (Delaney, Lacroix, Leclerc, & Johnston, 2002), and 20% of football players later diagnosed with concussion returned to play because symptoms were not identified until after the game (Delaney, Lacroix, Leclerc, & Johnston, 2000; Guskiewicz, Weaver, Padua, & Garrett, 2000). Kaut, DePompei, Kerr, and Congeni (2003) found that more than half of collegiate athletes did fully not understand the symptoms associated with concussion, although a majority identified a basic awareness of physical (e.g., loss of consciousness) and cognitive (e.g., memory problems) symptoms postinjury. Other research has shown football players to be more knowledgeable about the symptoms of concussion compared with controls (Simonds, 2004). However, this same research also revealed that football players are more likely to believe it is acceptable to continue play despite concussion symptoms such as confusion or pain. This latter finding may suggest football players are less knowledgeable about the long-term consequences of concussion (Simonds, 2004). This pattern is consistent with the incomplete knowledge of concussion symptoms found in many
CONCUSSION KNOWLEDGE IN ATHLETES
coaches (Mrazik, Bawani, & Krol, 2011; Valovich McLeod, Schwartz, & Bay, 2007) and the tendency of some coaches to downplay concussion severity (Buzzini & Guskiewicz, 2006). The current study sought to examine differences in concussion symptom knowledge between athletes and controls. Based on these data, we hypothesized that many student-athletes would have an incomplete understanding of concussion symptoms.
METHODS Participants Data were collected from 382 National Collegiate Athletic Association Division I athletes (228 men, 154 women) at a midsized Midwestern public university. Athletes ranged in age from 18 to 24 years old (Mage ¼ 19.57 1.24 years). Average years of playing experience at the collegiate level were 1.69 years (1.59 years). Separately, data from 230 college students (77 men, 153 women) not involved in collegiate sports were collected from this same Midwestern public university to serve as a control group. Control-group participants ranged in age from 18 to 27 years with an average age of 19.56 years (1.75 years). Measures Risk Perception Questionnaire (Appendix). The Risk Perception Questionnaire (RPQ) includes a checklist of 16 potential symptoms following concussion. This checklist was developed for the current study using items from the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Revision (American Psychiatric Association, 2000) that are commonly associated with concussion. Specifically, the RPQ checklist includes four distractor items (i.e., relationship problems, excessive sweating, seeing or hearing things that are not there, and forgetting names or faces of people you know well) not related to concussion symptomatology that can be used to help determine accuracy of expected symptoms. The symptoms that comprise the RPQ are generally similar to those found in the Postconcussion Symptom Scale (PCSS; McLeod & Leach, 2012; Pardini et al., 2004), with two key differences. The PCSS contains no distractor items, though it specifies directionality of symptoms (e.g., sleeping more=less than usual rather than any sleep disturbance). A composite variable was created that reflected the total number of symptoms endorsed on the RPQ, including any possible distractor items. The RPQ demonstrated adequate internal consistency in this
109
sample with a Cronbach’s a .74. Additionally, correlations between individual items and the total score ranged from a low of r ¼ .38 (headaches) to a high of r ¼ .56 (feeling depressed). Distractor items were retained for analyses to help discriminate levels of knowledge between student-athletes and controls. Immediate Postconcussion Assessment and Cognitive Testing. The Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) is a computerized neuropsychological test battery designed to collect demographic=medical data and quantify cognitive function in several domains (Lovell, 2007). The current study used only the self-report information from the ImPACT. Procedure Data were collected under different conditions for student-athletes and controls. All student-athletes completed all study measures as part of baseline preseason testing for their respective sport. These broad evaluations are conducted by a team of experts with backgrounds in medicine, athletic training, and neuropsychology. Most relevant to the current study, student-athletes presented for concussion-related measures in groups of approximately 15 individuals. They were then placed into separate exam rooms to complete the RPQ and ImPACT. To avoid possible inflation of symptom report and=or demand characteristics (Edmed & Sullivan, 2012), the RPQ was administered before the ImPACT. The number of concussions was obtained through self-report from the athletes during this evaluation and was verified by athletic training staff, though no severity information was available for the current study beyond athletes missing at least one practice. Undergraduate controls completed the RPQ and provided basic demographic=medical information during individual testing sessions. Unlike the student-athletes, controls did not complete the ImPACT and did not receive one-on-one supervision during completion of study measures. Controls received research course credit for their participation. Data Analysis A series of analyses examined differences in concussion knowledge between student-athletes and controls. First, t tests were used to examine the total number of expected concussion symptoms between student-athletes and controls, and then these results were clarified through t tests on each subtype of concussion symptoms (i.e., distractor, somatic, cognitive, emotional, sleep). For these analyses, group membership (i.e., student-athlete vs. controls)
110
FEDOR & GUNSTAD
served as the dependent variable with the individual symptoms being the independent variable. Chi-square analyses were then used to investigate possible differences in endorsement rates of specific symptoms between student-athletes and controls. Finally, analysis of variance (ANOVA) was used to examine whether student-athletes across various sports expected different numbers of symptoms following a concussion compared with controls. For this analysis, the independent variable was group membership (i.e., individual sport played vs. control), while the total number of expected concussion symptoms served as the dependent variable. As multiple comparisons were performed, a Bonferonni adjustment was applied to reduce the risk for possible Type I error.
RESULTS Student-Athletes Differ From Controls on Concussion Symptom Knowledge T tests showed student-athletes (M ¼ 11.15 4.06 symptoms) expect significantly more symptoms following concussion compared with controls (M ¼ 9.64 4.37 symptoms), t ¼ 4.33, p < .001. T tests revealed student athletes expected significantly more distractor (1.19 1.05 vs. 0.84 0.89), somatic (6.05 1.76 vs. 5.30 2.12), and cognitive (2.31 0.90 vs. 2.01 1.10) symptoms compared with controls. No significant differences emerged for emotional or sleep symptoms. See Table 1. Chi-square analyses revealed that student-athletes were more likely than controls to endorse the likely presence of a number of symptoms following a concussion, including nausea and=or vomiting, sleep disturbance, and forgetfulness or poor memory. See Table 2. Examination of specific symptoms revealed that many student-athletes expected to experience headaches (94.8%), dizziness (90.3%), and nausea and=or vomiting (77.5%) after suffering a concussion. However, 70.4% of student-athletes also endorsed the distractor item
TABLE 2 Patterns of Symptom Endorsement Between Student-Athletes and Controls
Symptom Distractor Symptoms Forgetting names or faces of people you know well Relationship problems Excessive sweating Seeing or hearing things that are not there Somatic Symptoms Headaches Feelings of dizziness Nausea and=or vomiting Easily upset by loud noises Tiring more easily Blurred vision Easily upset by bright light Double vision Emotional Symptoms Being irritable, easily angered Feeling depressed Feeling frustrated or impatient Cognitive Symptoms Forgetfulness, poor memory Poor concentration Taking longer to think Sleep Symptoms Sleep disturbance Restlessness
Student-Athletes
Controls
% Endorsing Yes
% Endorsing Yes
70.4
49.1
10.5
8.3
0.81
.37
15.4 22.5
10 17.0
3.67 2.73
.06 .09
94.8 90.3 77.5
91.7 89.1 68.7
2.20 0.22 5.79
.14 .64 .01
61.5
43.0
19.77
