Awareness of Concussion-Education Requirements, and -Management Plans and Concussion Knowledge in High School and Club Sport Coaches

During the 2017–2018 school year, almost 8 million adolescents participated in high school sports.¹ With an increase in sport specialization among youth athletes, more adolescents may be choosing to join non–school-affiliated club teams with the goals of training year-round and earning college scholarships.^2,3 In 1 study,⁴ nearly half of high school athletes reported that they participated on a club team not affiliated with their high school team. In a survey⁵ of collegiate athletes, approximately 90% of soccer, basketball, and volleyball players had participated in their sport on both high school and club teams before college.

For high school and club athletes, injuries, such as concussions, pose health risks. An estimated 1.1 to 1.9 million sport- and recreation-related concussions occur annually in youths aged ≤18 years.⁶ The Centers for Disease Control and Prevention defined a concussion as “a type of traumatic brain injury caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move quickly back and forth.”⁷ All 50 states and Washington, DC, have passed laws regarding concussions in youth sports.⁸ The state laws for concussion-management plans and coach concussion education for high school teams and other youth sport organizations, as obtained from a review of each state's concussion legislation, are provided in Table 1. All states except Georgia require high school coaches to receive educational materials or undergo training about concussions. Fewer than half of state concussion laws extend the same requirements to club sport coaches. Concussion recognition and proper management are important aspects of concussion education for coaches, who can play a key role in recognizing these injuries and removing injured athletes from play.^9,10 Continuing to play while experiencing concussion symptoms has been associated with prolonged recovery, increased risk of incurring a second concussion, and a greater likelihood of a poor outcome after the injury.^11,12 Coaches with greater knowledge of concussions may be better able to identify athletes experiencing concussion symptoms and guide them to appropriate medical personnel.^13–15

Table 1 State Law Requirements for Concussion Education for Coaches and Concussion-Management Plans^a in Schools or School Districts and Other Youth Sport Organizations

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The role of coaches in concussion recognition, athlete concussion reporting, and proper management of the injury is especially critical when an athletic trainer (AT) or other medical professional with concussion training is not available. In a recent study,¹⁶ approximately 65% of high school coaches and 39% of club coaches stated that an AT was present at competitions most or all of the time. Only 30% of high school coaches and 8% of club coaches indicated that ATs were present at most or all practices.¹⁶ If an AT was not responsible for immediate medical care at either a practice or competition, both high school and club coaches most frequently acknowledged that this responsibility was theirs.¹⁶ Therefore, coaches must be able to recognize concussion symptoms and understand the appropriate steps to take if they suspect an athlete has sustained a concussion. The purpose of our study was to evaluate whether differences in concussion education, concussion-management plans, and concussion knowledge existed between high school coaches and coaches of club sport teams consisting of high school-aged athletes.

METHODS

Questionnaire

Questions for this study were part of a larger questionnaire used to examine emergency preparedness factors, medical coverage, emergency-care training requirements, and sport specialization. Questions examined in the present study composed 3 sections: (1) demographics and teams coached, (2) requirements for concussion-education and concussion-management plans from the coach's organizing body or league, and (3) concussion-knowledge questions. Specific questions of interest for this study are presented in Tables 2 through 4.

Table 2 Comparative Demographics of High School and Club Sport Coaches

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State concussion laws were obtained from individual state government Web sites and databases through June 28, 2019. We examined the laws for requirements regarding concussion education and training for coaches, a concussion-management plan for each institution or organization, and whether these mandates applied only to schools or also to other sport organizations.

A modified version of the index designed by Chrisman et al¹⁷ was used to measure general concussion knowledge among high school and club sport coaches. We adapted 5 of the original statements from this index for use in our survey: “Most concussions (>80%) resolve within 7 to 10 days,” “It is safe for a player to go back into the game if concussion symptoms last less than 15 minutes,” “After having a concussion, an athlete has a higher risk of getting a second concussion,” “Loss of consciousness is required to diagnose a concussion,” and “Returning to play while having symptoms of a concussion can slow recovery.” Responses to the questions were scored on a 7-item Likert-type scale, ranging from 1 (strongly disagree) to 7 (strongly agree).

Statistical Analysis

Likert-scale responses were reduced to binary variables to indicate the answer for each question. This allowed us to analyze the coaches' actionable beliefs about the items rather than their confidence levels in their responses. Somewhat agree, agree, and strongly agree were grouped into an agree category, whereas somewhat disagree, disagree, and strongly disagree were grouped into a disagree category. Agree was the correct answer for 3 of the 5 questions, and disagree was the correct answer for 2 questions (Table 4). Neither agree nor disagree was considered incorrect for all questions and grouped with the incorrect response (either the agree or disagree category) for each question.

Table 3 High School and Club Sport Coaches' Awareness of Receiving Concussion-Education and Concussion-Management Plans

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Table 4 Concussion Knowledge Between High School and Club Sport Coaches

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Demographic data were summarized as frequencies with proportions (in percentages) and means with standard deviations. Chi-square analyses were calculated to compare differences in demographic factors between groups, except for age, which was compared using an independent t test. Chi-square analyses were also conducted to compare the frequency of responses to all concussion questions between high school and club coaches. To determine whether demographic differences between high school and club coaches influenced their awareness of concussion-education requirements, concussion-management plans, or concussion knowledge, we performed secondary χ-square analyses to compare responses based on the sport coached and education level. We used SPSS (version 25.0; IBM Corp, Armonk, NY) for all analyses. The α level was set at .05.

RESULTS

Several demographic factors differed between high school and club coaches (Table 2). Basketball coaches were more likely to identify as high school coaches (high school = 40.8% versus club = 32.0%), whereas volleyball (high school = 30.6% versus club = 38.2%) and soccer (high school = 28.6% versus club = 29.8%) coaches were more likely to identify as club coaches. More high school than club coaches reported that they had earned a graduate or professional degree (48.3% versus 31.3%), and more club than high school coaches reported they had earned an associate or 2-year college degree (17.6% versus 8.5%) or a bachelor's or 4-year degree (46.0% versus 36.4%). Awareness of whether their parent organizations had a concussion-management plan differed among basketball, volleyball, and soccer coaches, with soccer coaches most likely to report that their parent organizations had a concussion-management plan (basketball = 84.5%, volleyball = 81.3%, soccer = 91.9%; χ²₄ = 14.9, P = .005; see Supplemental Table 1). The requirements for concussion education and concussion knowledge did not differ based on sport coached (P > .05; see Supplemental Table 2). No differences were found in responses to any concussion questions based on coach education level (P > .05; see Supplemental Tables 3 and 4).

More high school than club sport coaches reported that they were required to receive educational information about concussions from their organizing bodies or leagues (97.4% versus 80.4%; χ²₂ = 64.3, P < .001; Table 3). Similarly, high school coaches were more likely than club coaches to report that their organizing bodies or leagues had a concussion-management plan (94.0% versus 70.2%; χ²₂ = 84.6, P < .001).

More high school than club coaches correctly agreed that most concussions resolve in 7 to 10 days (48.6% versus 40.1%; χ²₁ = 5.1, P = .02; Table 4). However, fewer than half of all respondents answered this question correctly (45.6%, n = 350/768). Additionally, more high school than club coaches correctly disagreed with the statement, “Loss of consciousness is required to diagnose a concussion” (87.1% versus 80.9%; χ²₁ = 5.3, P = .02). High school and club coaches did not differ in their responses to the 3 additional concussion-knowledge questions.

DISCUSSION

We found a difference between high school and club sport coaches for concussion knowledge, as well as awareness of requirements for concussion-education and -management plans. Compared with high school coaches, fewer club coaches reported that they were required to receive concussion education. Club sport coaches in Illinois, Michigan, Minnesota, and Wisconsin were surveyed in this study, and these states' concussion laws require or encourage (Illinois) concussion education for coaches in any youth sport organization, including those not affiliated with public or private schools. However, 17% fewer club than high school coaches knew whether their organizing bodies or leagues required them to receive concussion education. Several factors could have contributed to this finding. It is possible that the organizing bodies or leagues were not aware that the laws in these states applied to their organizations, were poorly communicating the requirement for concussion education to their coaches, or were not enforcing or complying with the laws within their organizations. Previous authors¹⁸ have suggested that the lack of a formal compliance or enforcement mechanism in state concussion laws was a barrier to effective implementation. Interscholastic athletic associations, departments of education, or both may be providing greater oversight and enforcement of these laws within high schools, whereas a lack of similar oversight or ineffective enforcement for club sport organizations may result in downstream consequences that contributed to our findings. Additional research is needed to explain why fewer club coaches were aware of their concussion-education requirements.

More high school than club coaches answered concussion-knowledge questions correctly in this study, which may be related to the coaches' lack of awareness of their leagues' requirements. Investigators^13–15 have proposed that coaches with greater concussion knowledge may be more likely to identify a concussed athlete, appropriately remove that athlete from play, and ensure that the athlete receives proper medical care and clearance before returning to play. As shown in Table 1, concussion education or training is required only for coaches in club or other youth sport organizations in 20 states (42%) and Washington, DC. Four additional states encourage concussion education for non–school-affiliated youth sports organizations, and another 3 states require concussion education for outside organizations using school or other public facilities. Given the rise in sport specialization and club sport participation in recent years^2,3 and the responsibility that club coaches have in their athletes' medical care,¹⁶ it is concerning that club sport coaches are held to a different standard regarding concussion education and knowledge than those who coach high school athletes.

As with concussion education, fewer club sport coaches reported that their organizing bodies or leagues had a concussion-management plan. A total of 94.0% of high school coaches said their school had a concussion-management plan, whereas only 70.2% of club coaches reported the same. All state concussion laws discuss the appropriate management of a concussion. However, among all states and Washington, DC, only 18 (35.3%) required schools or school districts to create their own concussion-management plan, and only 5 (9.8%) required non–school-affiliated youth sports organizations to have their own plan (Table 1). One additional state encouraged youth organizations to have their own plan, and 2 others had this requirement only for organizations using school or other public facilities. Of the 4 states in this study, only Illinois required schools to have a concussion-management plan, whereas none of the states required that of club sport organizations. Researchers should investigate whether having a concussion-management plan influences high school and club coach concussion knowledge and the proper management of concussions in their athletes.

High school coaches (48.6%) correctly agreed with the statement, “Most concussions (>80%) resolve within 7 to 10 days,” more frequently than club coaches (40.1%). Notably, fewer than half of all coaches responded to this statement correctly, whereas at least 80% of coaches responded correctly to all other concussion-knowledge statements. This timeline is primarily based on research published in the 1990s and early 2000s,¹⁹ but more recent authors^19,20 have suggested the average recovery time may be longer than originally thought (ie, within 1 month of injury). It is possible that some coaches answered this question based on their personal experience with concussed athletes who had a longer average recovery time. More concerning is that some coaches may be allowing their athletes to return to play prematurely, especially in settings without an AT, leading them to underestimate the average recovery time.¹⁶ Researchers should further investigate what coaches believe is the average time to recovery from concussions and return to play and the reasoning behind their estimates.

For decades, loss of consciousness (LOC) has not been required for a concussion diagnosis.²¹ However, more club (19.1%) than high school (12.9%) coaches indicated that they believed LOC was necessary for a concussion to be diagnosed. These values are consistent with studies^13,14,22 of youth sports coaches' concussion knowledge. In 2007, Valovich McLeod et al²³ found that 42% of youth sport coaches believed that a concussion only occurs when an athlete experiences LOC. Mandated concussion education may have resulted in improved coach knowledge regarding LOC and concussions over the past decade. The fact that 12.9% to 19.1% of coaches overall still subscribed to this common misconception is troubling. Given that most concussions do not result in LOC, this misconception may lead to concussions going undiagnosed, particularly when an AT is not present and the coach is responsible for the team's medical care.

High school and club coaches differed on some, but not all, of their answers to the concussion-knowledge questions, which may be due to receiving information from sources other than formal concussion-educational materials. Mrazik et al²² observed that coaches most often obtained concussion information from magazines and newspapers, whereas the internet was the second most frequent source. Information about removal from play and same-day return to play has been a focus of concussion laws, as well as media coverage about concussions.²⁴ Short-term and long-term consequences of poor concussion management have also received media attention over the past decade.²⁴ Media coverage could be responsible for the lack of difference in responses to these questions despite fewer club coaches reporting that they received concussion education from their organizing bodies or leagues. It is also possible that some club coaches currently or previously coached a high school sport and received concussion education in that setting. We did not obtain information about previous or concurrent coaching roles in this study.

Coaches play an important role in setting the culture and expectations for safety and reporting among their teams.^9,20,25,26 Several researchers^10,27 have suggested that approximately half of concussed athletes continue to play while experiencing symptoms without reporting their injury. Continuing to play with a concussion can have serious consequences, including an increased risk that the vulnerable brain will sustain a second concussion, resulting in the athlete's experiencing prolonged recovery from the original injury, delayed return to play, and persistent difficulties in the classroom.^11,12 Numerous factors can influence an athlete's decision not to disclose the injury, including not wanting to let the coach down, perceiving pressure from the coach to continue playing, or perceiving that the coach did not support reporting of the injury.^15,26,28,29 Chrisman et al²⁹ examined barriers to reporting concussion symptoms through interviews with high school athletes. Some players stated that their coaches set clear expectations and made them comfortable reporting concussion symptoms, whereas other players reported negative experiences or pressures not to disclose the injury. Of particular interest to us, 1 female soccer player reported that she began perceiving pressure to play through symptoms when she joined her club team. Coaches' concussion knowledge may affect their attitudes and beliefs toward concussion reporting, which in turn can influence the reporting culture of the teams that they coach.²⁵ This raises important concerns, given our results about the lack of education and knowledge reported by club sport coaches.

Two demographic characteristics differed between the high school and club coaches: sport coached and educational attainment. Sport coached only influenced coach awareness of their parent organizations requiring a concussion-management plan, and the educational level did not influence responses to any concussion questions. Concussion rates were higher in soccer than in basketball and volleyball.³⁰ The higher concussion rate may have resulted in more soccer leagues developing and distributing concussion-management plans to coaches.

Our study had several limitations. Because of the geographic distribution and response rate, it is possible that our results are not generalizable. Budget constraints restricted our recruitment of high school coaches to only 1 state. Recruitment of high school coaches from 1 state and club coaches from several states may have influenced the findings regarding concussion management, education, and knowledge. All states from which club sport coaches were recruited have similar concussion laws requiring education of coaches from non–school-affiliated sport organizations, but enforcement of these regulations may vary across these states. Club coaches may have also received concussion education from sources other than their current organizing bodies or leagues. Moreover, club coaches may have coached high school teams previously or concurrently and received concussion education in that setting. Future researchers should address additional sources of information, as well as other factors that may influence concussion education and management in the club sport setting.

Given that many athletes see club sports as a key to college recruitment² and consistent with the perception of increased pressure to play through an injury on club teams observed by Chrisman et al,²⁹ coaches in the club sport environment may add to pressure promoting nondisclosure of concussion symptoms. Adequate concussion knowledge does not always reflect attitudes toward concussion-management or concussion-reporting behaviors.²⁸ However, we only addressed concussion education and knowledge among high school and club sport coaches. Investigators should examine coaches' attitudes and intentions toward concussion management and the effect on team reporting culture between high school and club sport teams.

CONCLUSIONS

Fewer club than high school coaches were aware of concussion education and requirements by their organizing bodies or leagues despite all being located in states with concussion laws that mandate concussion education for both interscholastic sports and private sport organizations. Similarly, club coaches displayed less concussion knowledge and were less likely to be aware of whether their leagues or organizations had a concussion-management plan. These results raise concerns regarding the proper management of concussions in club sports and suggest the need for greater oversight and enforcement of state laws in the club sport setting. Greater attention to club sport enforcement of concussion laws and efforts in concussion education may be needed to address gaps in concussion knowledge between high school and club coaches.