“Play through it”: Delayed reporting and removal from athletic activity after concussion predicts prolonged recovery
Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, and Bauer RM. J Ahtl Training. 2016. 51(4): 329-335.
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Take Home Message: Athletes who immediately stopped activity and reported symptoms of a concussion typically missed fewer days before returning to activity than athletes who delayed reporting such symptoms.
Despite increased awareness about concussions and their consequences, some athletes fail to report their concussive symptoms to a medical professional and continue to participate in sport. To date, no one has evaluated the consequences of continuing to play after a concussion on recovery time. Therefore, Asken and colleagues completed a retrospective study to examine the association between delayed reporting and removal from athletic activity on concussion recovery time. Researchers reviewed medical records of 97 athletes diagnosed with a sports-related concussion. They extracted data pertaining to learning disabilities, psychological disorders, concussion history, and symptoms. Overall, 47 athletes were removed from activity immediately following a concussive event while 50 athletes delayed reporting their symptoms. The researchers found that athletes who were not immediately removed from activity were more likely to have a delayed recovery period (approximately 5 days longer) than those athletes who were immediately removed from sport. The athletes who failed to immediately report their symptoms and continued to play were also more than twice as likely to need more than a week before returning to play.
Overall, these results help clinicians by providing evidence that immediately reporting concussion symptoms may be associated with less time missed due to a concussion. While not part of this study, it is believed that some athletes do not report symptoms for fear of not being able to participate; however, the current study suggests that not reporting symptoms may result in more time being missed. One reasonable explanation for these results is that athletes who withhold reporting their symptoms may actually be exposing themselves to more head impacts, which may result in a more severe injury. One note of caution, however is that all data in the current study were ascertained via medical records and thus are subject to human error and bias. Further, not all athletes were assessed by the same clinicians or with the same assessment tools. To better understand the impact of delayed reporting of concussions, future studies should attempt to track athletes prospectively, which would allow researchers to standardize the assessment component much more clearly. Until this can be done, however, this study should be used by clinicians as an educational tool for athletes to encourage timely and honest reporting of all concussion-like symptoms.
Questions for Discussion: What do you currently do to encourage your athletes to self-report concussions? Do you feel these approaches have been successful? Why or why not?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, & Bauer RM (2016). “Playing Through It”: Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. Journal of Athletic Training, 51 (4), 329-35 PMID: 27111584
I do believe that under-reporting symptoms or not reporting symptoms at all could lead to more time lost but this also could be due to the fact that their return to play protocols begin later as well. Depending upon the protocol, the athlete could be symptom-free and still not fully participating within five days of reporting symptoms.
As means to encourage students to self-report symptoms, we present the dangers of second-impact syndrome and the consequences of continuing to play through a concussion to the athletes and to the coaches in an effort to prevent further injury. I believe that the more aware these athletes are becoming of the seriousness of concussions, the more they are reporting symptoms. From my experience, I feel these approaches have become successful due to education of athletes, parents, and coaches.
The question posed at the end of this article review would be a great area for future research. What exactly are athletic trainers and health care professionals doing and saying to encourage athletes to self-report concussion symptoms? Is information relayed to athletes during an annual pre-season or pre-academic year presentation? Are athletes given handouts? Do athletes complete online training modules over sport-related concussions? I believe a study that answers some of these questions and explores the efficacy of the various methods health care professionals use to educate athletes about sport-related concussions would be interesting.
I believe that concussions are absolutely under-reported, but I do think that now concussions are getting the attention they deserve from media, Athletic Trainers, coaching staffs, and parents. Since concussion has become such a "hot topic" I think that it has made many more people education on what they really are. I think that to encourage athletes to self report, educating them is key. I am very up front on concussion at the beginning of each season and I make it known that the athletes need to come to me with symptoms. I have worked mostly at the collegiate level and those athletes were heavily educated on concussion. From conversations I have had with athletes, they have said that long term negative outcomes is what makes them report concussion since they know that they will most likely not be playing their sport forever.
Thanks for the comment. I think it sounds like you are being very proactive in your approach. I think the education component is the route to take, but I do start to worry that concussions are becoming such a "hot topic" and Aleah put it, are we drowning ourselves out? Are we educating so much that athletes are no longer taking what we say to heart?
I think you are in line with my previous comment directed at Haley. Perhaps this is a call for research into how to effectively reach out athletes. I know I would love to use this evidence based practice model in my clinical education. As professionals that are often stretched thin on time and resources, maybe some dedicated research on efficacy of patient education would be helpful. Great comment!
Education is the key. It is important to educate the student athletes at the beginning of every season and to emphasize the importance of reporting symptoms of concussion immediately. Unfortunately, communication is an issue in most cases. It is necessary to develop and maintain open channels of communications from the athletic trainer to the athletes in order to prevent delayed reporting of concussive symptoms. Making the information available to the athletes makes it easier for them to understand and come forward as needed. I feel as though it is vital for the athletic trainers to reveal information regarding concussion at the pre-season meeting in order for all of the players to be on the same page as well as the staff and coaches. Sharing information regarding the return to play process with the athletes and coaches provides them with the proper information to come forward with symptoms. I am hopeful that presenting the information could make a big difference. In order to get the point across, I feel as though a mixture of presenting the facts about concussion in an easy to understand manner as well as the consequences of not reporting concussions could play a huge role. The challenge comes with the fact that the information has been presented and the athletes have to make the ultimate decision to come forward.
I believe this would be a great research article to have pinned up and highlighted for student athletes or to present to them during PPE's. It highlights the importance of early detection and reporting to keep them safe and return to sport quicker. If you place emphasis on the 5 days on average longer return to play, I think this could really hit home to some athletes.
That being said, I think a possible cause for the ~5 days of longer return to play between the groups was due to late detection of the concussion which then the medical providers implemented a return to play protocol on the day of reported symptoms. This delay in the implementation of protocol coupled with the injury date and an injury first reported date could cause some misinterpretation of data.
That being said, I still believe that quicker recognition and reporting of concussions will ultimately result in a quicker return to play and better long term outcomes.
The findings of this article coincide with what I've experienced clinically. Athletes who are more self aware of their symptoms and realize what they are experiencing isn't normal and report their concussion tend to recover quicker. One of the challenges I have faced clinically is that some athletes experience headaches following a hit to the head, and assume the headache is just because they hit their head hard, not because they have a concussion. At that point I began to realize that educating athletes is critical in having athletes self report their concussion symptoms. One step I've always tried to make in educating the athlete and having them self report symptoms is telling them that I'm trying to help them, and I'm not simply trying to remove them from participation.
One thing that is beginning to benefit athletic trainers, is how often concussion (and its negative impacts) are in the news. Athletes are beginning to realize how relaying information about their concussions is important, as they are beginning to worry about the negative long term side effects. In combination with their fear of concussions, its important to educate them on what they need to report to athletic trainers, and help them understand that their own health is far more important than a few extra minutes in a game.
Thanks Catherine! I like the idea of teaching the athletes each year about concussions and how they are handled and why. If you start when the kids are young you can imagine that by the time they are older it'll be ingrained in them. It's important to also explain the consequences of not reporting or taking a concussion serious so they can appreciate why we're so focused on this. Some of these concepts could be integrated into just a welcoming talk from the AT about injuries in general and how they are handled and why they are handled that way.
Landon, I agree. If one didn't want to hang the article you would think an infographic could be produced or a simple summary statement.
Landon and Tyler, I think you both brought up some other points that could help explain the findings. Thanks!
I really enjoyed your comment regarding the point of emphasis for athletes. One thing that I found in my clinical practice is that often athletes were uncomfortable reporting signs and symptoms of concussions for fear of getting pulled from activity with no regards for the athlete's desire to play. While this is sometimes necessary I think that if athletes really believe that the athletic trainer is wants them playing they would be more willing to work together. With that, I need to again comment that the athlete's future health and safety is paramount and should never be jeopardized. But I think we can do a better job as clinicians communicating our decisions and desires to our athletes.
Catherine, to your point. It all comes back to effective communication!