Sport Concussion Management Using Facebook: A Feasibility Study of an Innovative Adjunct “iCon”

Sport concussion is currently considered a “hot topic” in both the mainstream media^1,2 and the scholarly literature.^3,4 The effects of concussion have dominated the dialogue in many professional sports,^5–7 and its implications have been recognized at the amateur level.⁸ The cost of sport concussion can be defined in financial⁹ and societal terms¹⁰ as well as its effects on wellbeing (health).¹¹ Due to these consequences, much focus has been placed on technologies that can aid in the detection of concussion^12,13; however, less attention has been placed on facilitating and managing recovery after concussion. Given the significance of sport concussion as a leading public health concern,¹⁴ it is prudent to explore a wide array of approaches to facilitate the recovery of individuals after a sport concussion and to assist athletic trainers in this process.¹⁵

An area of health care that has not been fully explored with respect to sport concussion is eHealth, which is defined as “health services and information delivered or enhanced through the Internet and related technologies.”¹⁶ Whereas early eHealth interventions were centered on simple communication methods such as text messaging,¹⁷ the sophisticated nature of the Internet has led to more nuanced approaches to online health interventions.¹⁸ The advent and widespread use of social media has been a factor in this process.¹⁹ Social media (including platforms such as Facebook, Twitter, and YouTube) are now ubiquitous throughout society and are widely used for a variety of everyday purposes, including as a popular adjunct to health care.^20–22

The use of evolving technologies to assist in the management of sport concussion has been described in the clinical literature,^23,24 and there is also a growing awareness of the role that technology can play in the detection of sport concussion.^25,26 Multiple smartphone applications (apps) are tailored for sport concussion.^27,28 In a systematic review, Lee et al²⁵ demonstrated that the currently available concussion-related apps are targeted at a wide range of consumers (including medical professionals, the general public, and the parents of young sportspersons). The content of the concussion information in these apps varied in its quality and consistency; many concussion-related apps failed to provide consumers with information that adhered to best-practice guidelines.²⁵

Researchers have described the use of Web sites and social media for the dissemination of concussion-related information. In an earlier study, Ahmed et al²⁹ evaluated the content of concussion-related Facebook groups and used the term iSupport (interactive support) to describe the process by which persons with concussions were communicating and seeking support. The same authors also analyzed concussion-related Web sites and found that the quality of online information available for consumers was inconsistent,³⁰ although further investigations^31,32 have been conducted into the content of concussion-related information on Twitter and YouTube. Facebook support groups have been shown to be beneficial for a range of conditions, including breast cancer³³ and diabetes,³⁴ and for the parents of preterm infants.³⁵ The use of innovative strategies and technologies to assist in the diagnosis and management of concussion has been recognized and recommended in the Concussion in Sport (CIS) consensus statement³ and the National Athletic Trainers' Association position statement.¹⁵ Furthermore, social media have been cited as a means of facilitating concussion education.³⁶

Given the widespread use of social media (in particular, Facebook) and the high prevalence of sport concussion in the younger population, an exploration of the use of Facebook to assist individuals in managing the recovery process was indicated. Therefore, the aim of our study was to establish the feasibility of a Facebook concussion-management strategy termed iCon (interactive concussion management) to facilitate the management and safe return to play (RTP) of young persons with sports concussion. The successful implementation of a concussion-management adjunct such as iCon could lead to a range of benefits, including providing the patient with interactive and real-time feedback, giving athletic trainers an additional tool to help manage their players' RTP and potentially easing some of the burden on the patient's medical provider.

METHODS

Design of iCon

Authors of previous related studies^29,30 indicated that online resources were a potentially valuable means of assisting an individual with a concussion. Before the creation of iCon, Ahmed³⁹ consulted with different key stakeholder groups: namely, young persons with sport concussions and the primary care physicians responsible for their care.⁴⁰ These primary stakeholders were supportive of Facebook being used in this manner. An explorative study was also undertaken of the ethical concerns related to the use of Facebook to deliver a concussion intervention,⁴¹ and these concerns helped to shape the creation of the iCon content and operation.

iCon was designed to augment the face-to-face interactions individuals had with their primary care physicians. A Facebook group that was designed specifically for this trial, iCon contained the following key features:

• Best-practice concussion information at the time of the study

• The ability to obtain real-time feedback from experienced medical personnel

• A vehicle for peer support via interaction in iCon with other individuals who had sustained a concussion

For the purposes of privacy and confidentiality, iCon was established as a “secret” Facebook group. This ensured that only the participants in iCon would be able to see the information posted within the group and that individuals external to iCon would not be able to view its contents. Given that elite sportspersons typically have access to high-level medical services and have different needs from those of recreational athletes, iCon was targeted as a community-based intervention for nonprofessional athletes.

iCon Content

All advice and recommendations in iCon were based on the most up-to-date concussion information at the time the study was conducted, namely, the 2008 international consensus statement.⁴² Since this study was completed, these guidelines have been superseded by the 2012 international consensus statement³; however, the main premise relating to concussion management is unchanged. The key content features of iCon are outlined in Table 1.

Table 1.  Key Content Features Incorporated Into iCon

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iCon Staff

Two individuals were responsible for providing input during iCon: the iCon facilitator (iCF) and the iCon physician. The iCF (O.H.A.) was responsible for the day-to-day management of iCon, posted information relating to concussion, and answered any questions raised by the participants. The iCF was a sports physical therapist trained at the postgraduate level, who had 9 years of clinical experience (including 5 years of working in elite sports) at the time of the study. The iCF recorded details relating to participant interactions during the pilot study and monitored iCon on a daily basis (minimum 3 times per day, 7 days per week, for the 90 days of the trial). A Facebook profile was created for the iCF specifically and solely for the purposes of this study. This profile contained information relating to his professional and academic credentials but none relating to his personal life, hobbies, or interests. Any medical questions that were outside the iCF's scope of practice were referred to the iCon physician. The iCon physician served as a consultant. Queries were forwarded to the iCon physician by e-mail, and his replies were posted on iCon by the iCF. The iCon physician was a primary care clinician at a university health center, had significant experience working with sports teams and young persons' health, and had frequently encountered sportspersons presenting with concussion as part of his clinical caseload.

Participants

The target population was males and females between the ages of 16 and 30 years who had sustained a recent concussion⁴² while playing a recreational or competitive sport. Participants included those with a medical diagnosis or self-reported symptoms of concussion after an injury mechanism, as defined in the 2008 consensus statement.⁴² Individuals were not required to have a medically confirmed diagnosis of concussion before registering for the study, nor were they required to be cleared before their RTP (although this was strongly encouraged through their participation in iCon). If they had not already done so, all participants in the study were advised to seek medical review after their concussion. Individuals could not enroll in the study fewer than 3 days postinjury in order to provide them with cognitive rest after their injury, and they had to consent to participation. To participate in iCon, all individuals had to either have a Facebook account or be willing to create one for the purposes of the study and had to have regular access to the Internet for the duration of their participation.

Sport concussions were the sole focus of this study, and individuals with a concussion originating from other causes (eg, road traffic accidents) were excluded. This was due to the particular needs (specifically, in RTP) associated with a sport-related concussion. The age range (16−30 years) reflected the demographic group at the highest risk of concussion due to their participation in contact and collision sports^43,44; participants were excluded if they were outside this age range. Participants were also excluded if their injury involved hospitalization for more than 48 hours (suggesting a more serious brain injury), if they were unable to communicate in English (either orally or in writing), or if they had concussion-like symptoms due to other reported neurologic conditions.

Participant Recruitment

Participants were able to enter iCon as soon as they had been identified and had consented. A comprehensive recruitment strategy in a provincial region of New Zealand was used that included referral from clinical staff members at medical practices and local sports injury clinics; poster advertisements at medical practices, supermarkets, sports centers, and university residential colleges; postings on Facebook groups relevant to the target population; e-mails to mailing lists for University students and staff; and word of mouth.

Once participants had consented to the study (using an online information form and consent sheet) and were enrolled in iCon, they were sent an introductory Facebook message welcoming them to the group. This message outlined the “house rules” for the group on topics including uploading and sharing links, videos, or photos; communicating with the iCF and iCon physician; and interactions with other iCon participants. Participants were invited to contribute to iCon as often as they felt comfortable, but no pressure was placed on them to contribute. Throughout the study, participants were informed that cognitive rest was a key component of early concussion management. They were therefore instructed to use iCon for short periods of time (no more than a few minutes at a time) in the early stages of their recovery from concussion and to increase their time spent participating in iCon as their symptoms subsided or if they felt this necessary or helpful.

On their entry to the study, participants were told that although iCon was likely to be of most value to them in the first 3 weeks after their concussion, they were welcome to stay in iCon after their symptoms resolved or diminished. The rationale for staying in the group was to allow those with experience and advice to serve as a support group and help newer participants, in keeping with the previous work of online support groups.⁴⁵ The 90-day period for iCon was chosen to coincide with the winter sports season, when a significant number of concussions generally are reported due to prevalent collision sports.⁴⁶ Although the intention was that participants would remain in the study until its conclusion, they were free to leave at any time.

Pre-iCon Interview

The purpose of the pre-iCon interview was to obtain information regarding user familiarity with Facebook, as well as injury information. The pre-iCon interview and post-iCon interview questions were generated by 3 members of the research team (O.H.A., A.G.S., S.J.S.), after exhaustive discussions regarding the major factors associated with the concussive injury, its management, and subsequent RTP. The structured pre-iCon interview was conducted by telephone by the iCF immediately before the participant entered iCon and collected demographic data and other information (Table 2). Data were also collected related to concussion symptoms and severity of symptoms per the Sport Concussion Assessment Tool 2 (SCAT2),⁴⁷ and concussion knowledge was described as a self-reported score. After the gathering of data from the pre-iCon and post-iCon interviews, relevant quotes that best illustrated the content theme were extracted. Irrelevant comments (eg, “you know” and “well, umm”) were removed; samples of the quotes are included in the “Results” section.

Table 2.  A Summary of the Key Information Collected During the Pre-iCon and Post-iCon Interviews

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At the end of the interview, the response to each question was read back to the participant for verification. Once the pre-iCon interview was concluded, the participant then provided the iCF with his or her Facebook username (eg, “Ed Knock”) and the e-mail address associated with the participant's Facebook account (eg, “edknock@hotmail.com”) to enable the facilitator to identify that account. Once the Facebook account was identified, the participant was added to the iCon group.

Post-iCon Interview

Participants were asked to inform (via Facebook message, e-mail, or telephone) the iCF once they had left the group, so the iCF could then arrange for the post-iCon interview to be conducted. For those participants who remained in the group until the 90-day study concluded, the follow-up interview was conducted after this time. The post-iCon interview was conducted by telephone within 1 week of exit from iCon (regardless of the mode of exit), and some of the content from this interview is outlined in Table 2. As with the pre-iCon interview, quotes were extracted from the post-iCon interview. At the end of the study, all participants were prompted to seek any further medical assistance relating to their concussion from their medical practitioner, if required.

Data Organization

In keeping with the theoretical underpinning of the study, it was important to gather data on several elements of the intervention to obtain a holistic understanding of how iCon functioned. Table 3 shows the participant demographic data, whereas the remaining data were classified into 3 broad categories:

Table 3.  Participants' Background Information and Symptom Scores

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• Outcome data: Included to show changes in the symptoms and knowledge of the participants (Tables 4 and 5)

• Operational data: Gathered to show how participants used iCon (Table 6)

• Evaluation data: Used to gauge the opinions of the participants toward iCon and their satisfaction with the support received from iCon (Table 7)

Table 4.  Concussion Knowledge and Concussion Learning (Summary Quotes and Explanatory Context Information)

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Table 5.  Influence of iCon on Return to Sport (Summary Quotes and Explanatory Context Information)

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Table 6.  Details of Facebook Use During iCon (Summary Quotes and Explanatory Context Information)

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Table 7.  Satisfaction With iCon (Summary Quotes and Explanatory Context Information)

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RESULTS

DISCUSSION

The primary goal of our study was to evaluate the feasibility of a novel and innovative approach to concussion management and, in doing so, to drive and inform future research. This innovative program is one of the first examples of a social-media approach to facilitate safe RTP after a sport concussion. One of the key findings was that all participants (N = 11) stated that they would recommend iCon to others. The post-iCon interview data indicated that iCon showed the potential to be successful on a larger scale, with supporting quotes such as “All questions asked were answered really quick, and it was easier than phoning the physician and asking for advice” (Participant No. 5), suggesting that the use of Facebook as an adjunct for concussion management appealed to this cohort of individuals. Other indications of iCon's success were the satisfaction scores and accompanying quotes, which reflected that the participants were predominantly very satisfied with the support they were given in iCon, from the iCF, iCon physician, and other participants.

A notable aspect of the intervention was that the majority (8/11, 73%) of participants stated that their RTP decisions were influenced by iCon. Education is recognized as crucial in the management of sport concussion,⁴⁸ and the importance of this knowledge-transfer process in concussion has been highlighted in the literature.^49,50 The post-iCon questionnaire data indicated that using iCon directly affected the participants' decision making in seeking a more conservative RTP; we inferred that the participants would also be better informed of the need to seek medical review in the event of a future concussion. Our study was not designed to analyze the long-term behavioral changes of the participants; thus, we have no way of knowing whether there were any long-term changes in this behavior or retained concussion knowledge.⁵¹

We anticipated that most participants in the study would see a reduction in their symptom scores regardless of their participation in iCon, and this was confirmed by the data. Although we assumed that the self-reporting of symptoms by telephone in the pre-iCon and post-iCon interviews was accurate, it must be acknowledged that differences in concussion-symptom reporting have been found between interviews and self-reporting questionnaires.⁵² Participant activity in iCon was not expected to be uniform, and it was thus unsurprising that 3 participants (No. 3, No. 4, and No. 11) had no activity at all recorded for their time on Facebook. This does not mean that these individuals did not use iCon during the study period but rather that they did not make any public postings in the group. It may have been that these participants demonstrated the behavior of “lurkers” (passive participants in online groups); a study⁵³ showed that lurkers may gain as much benefit from online groups as active posters. Although the post-iCon interview did not question this explicitly, the satisfaction scores for these 3 participants were high (4/5 or 5/5) and reflected some benefit from participating in iCon. Earlier work²⁹ has identified individuals with concussion supporting one another in Facebook concussion groups; however, in iCon, relatively little iSupport was witnessed among participants in terms of offering messages of support relating to concussion. It may have been that interactions occurred through private messages among participants in iCon, but we were not able to measure this because private messages are visible only to the sender and recipient.

Although the use of Facebook for social support by individuals with traumatic brain injury⁵⁴ and concussion²⁹ has been investigated, the use of Facebook by health care professionals to assist in recovery after a sport concussion is a new concept. This innovative method of interacting with concussed athletes is associated with myriad ethical factors,⁴¹ with a major consideration being the concept of cognitive rest.⁵⁵ The 2008 CIS consensus statement,⁴² which constituted the guiding principles at the time of this study, discussed the importance of cognitive rest after concussion, and this has been further reinforced in the most recent consensus statement.³ It could be argued that using Facebook when recovering from concussion is contrary to this advice. However, we agree with others⁵⁶ that total cognitive rest is impractical and that using social media for concussion management in a controlled manner could be beneficial to the recovery process. The 2012 CIS consensus statement³ did not advocate total cognitive rest; Gibson et al⁵⁶ also suggested that prolonged cognitive rest after concussion is not entirely advisable and should be approached cautiously. We took steps to address this factor; at the time of joining iCon, participants were clearly instructed to cease using Facebook if their symptoms worsened and to use iCon only for limited periods in the early stages after their injury.

Despite sustained efforts and an extensive recruitment process, only 11 participants were enrolled in the study, representing a relatively small sample. The timing of the study coincided with the winter sports season, when concussion rates were highest, and as a result, we expected that a larger number of participants would be recruited. Reasons for the relatively small sample size could include the lack of reporting or recognition of concussion. Several groups have highlighted that concussions are typically underreported in young rugby players^57–59 and in sports in general.^60–62 This lack of reporting would have limited the ability of local medical personnel to alert these individuals to the study. The process of knowledge transfer is possible only if individuals are keen to participate in their self-management, and this lack of engagement is a barrier that needs to be overcome if concussion interventions such as iCon are to be successful on a larger scale. Given the sample size in this group, success of this approach in a larger population cannot be guaranteed. The nature of an intervention such as iCon is that the information within it is fluid, and therefore, the content and advice could be targeted to a specific group, organization, or sporting code. This may be beneficial for athletic trainers working with different sporting populations and could assist in their efforts to manage concussion at a state level. Athletic trainers frequently have to manage sports concussions in their clinical environment, and novel methods to improve compliance with concussion management should be encouraged. In some instances, it is not appropriate or feasible for individuals with concussion to return to the clinic for follow-up: innovations such as iCon may serve as a mechanism athletic trainers can use across multiple environments.

Inclusion criteria for iCon did not specify that participants needed to be symptomatic to enter the group, only that they needed to have had a sport-related concussion within the past 3 weeks. As a consequence, several participants reported no or very few concussion symptoms on entry to iCon. It can be speculated that these participants might have benefited more from their participation in iCon if they were enrolled in the study sooner after their concussions, while they were still symptomatic, because the information given to them in iCon would have assisted in the management of their symptoms. Earlier identification and enrollment of participants would enable this to be evaluated. The financial implications involved are difficult to predict, but rolling out a system such as iCon on a larger scale may incur costs from the length of time needed for multiple clinicians to develop and maintain accurate information as well as review and respond to posts from participants. A final consideration is that the pre-iCon interview did not ask how participants primarily accessed Facebook; namely, whether they did this via a desktop computer at school, work, or the university; on a laptop computer; or via a mobile device (a cell phone or tablet such as an iPad). Further questioning about the method and location of access may provide additional insight into how participants accessed iCon and thus also help to shape the design of future online concussion interventions.

This interactive adjunct to traditional concussion-management strategies was appreciated among this participant group and indicated feasibility for a future, larger study of iCon. Given the relatively low number of participants in this trial, one way of ensuring larger numbers in the future would be to conduct a multicenter trial (especially given the current greater awareness of concussion). Larger participant numbers would have a consequential effect on the moderation of the group and may require more than 1 individual to perform the roles of iCF and iCon physician. Since this study ended, the use of smartphone apps for health, including in the field of sports medicine, has risen sharply.^25,63 Innovations such as online health interventions evolve and change over time⁶⁴; at present, the use of smartphone apps for concussion management is gaining attention.^25,65 In addition to a future trial of iCon, further exploration of concussion-related technologies is warranted to assess their role in assisting with the management of sport concussion.