United States Air Force Academy Cadets' Unprompted Knowledge of Concussions and “Bell Ringers” or “Dings”: Perceived Differences and Similarities

United States Air Force Academy (USAFA) cadets are at particular risk for sustaining a concussion, as reflected by the fact that 512 concussions were recorded among nearly 4100 cadets in slightly more than a 3-year span.¹ In order to seek appropriate medical treatment, an individual must first recognize that a concussion may have occurred.^2–4 Because not all signs and symptoms of a concussion are outwardly noticeable, the person experiencing possible concussion signs and symptoms must first acknowledge that what he or she is experiencing may be a concussion and then decide to seek medical treatment. Thus, recognition relates to concussion knowledge, and most concussion-education interventions have focused on concussion knowledge, including symptom identification.^5–8 Concussion knowledge has primarily been examined using researcher-driven “check all that apply” or Likert-scale surveys instead of open responses.^4,9,10 When people experience a suspected concussion, they likely do not have access to a list of symptoms to determine if what they are initially experiencing is indeed a concussion. Instead of merely recognizing symptoms on a list, individuals must recall them in an environment very different from that of most concussion-knowledge studies.¹¹ After any perceived concussion, the person still must decide, in the moment, whether to seek medical treatment.

More concussion knowledge does not necessarily relate to better concussion-reporting intentions or behavior.^3,5,12,13 However, as previously mentioned, one needs a basic knowledge of concussion signs and symptoms to recognize that what he or she is experiencing may be a concussion⁵ and begin the reporting process; hence, recognition is still an important step before disclosure. Typical concussion-knowledge tests may cue certain responses, but open response allows free recall, which may more accurately reflect contemporaneous knowledge and informal beliefs less likely to be anticipated by researchers. Our aim was to fill the gap in understanding how the cadets themselves described concussion with free recall using their words as data. The overall purpose of this study was to explore factors that led USAFA cadets to either disclose or conceal a concussion. Eight themes were discovered in the larger study¹⁴; the current article focuses on the theme and subthemes related to unprompted concussion knowledge. This portion of the study highlights how concussions are recognized and understood using free recall. Understanding these processes will allow us to create educational interventions with these principles in mind.

METHODS

The methods for this study were part of a larger study and have been described earlier.¹⁴ This study was approved by the USAFA Institutional Review Board before data collection. We recruited first- and third-year cadets in their mandatory behavioral science course and offered extra credit for study involvement. Participants completed baseline concussion assessments and a 5-minute concussion-education presentation approximately 9 to 10 months before data collection (approximately 10 months earlier for first-year cadets and about 9 months prior for third-year cadets). They checked a box on a consent form if they were willing to be interviewed (identity protection was ensured) and were reminded that they could stop the interview at any time without penalty. Two scripts were developed for data collection by 3 concussion and qualitative researchers: 1 for cadets with a concussion history and 1 for cadets without a concussion history (Table 1). Interview scripts were designed with a phenomenological philosophical framework¹⁴ and began with 2 introductory questions before proceeding to specific questions relating to the topic and then closing questions.¹⁵ In the study design phase, we anticipated that individuals with a concussion history and those without a concussion history might answer interview questions differently, specifically recalling a particular concussion event and their experience; however, the 2 scripts were mostly similar. Participants also completed a preinterview demographic form. We conducted pilot interviews before data collection and did not change the interview scripts after those interviews. Two members of the research team (M.L.W.R. and C.J.D.) conducted all interviews. Interviews were approximately 10 to 35 minutes long and were conducted until saturation was achieved for both scripts. We were confident that saturation was achieved after 12 interviews with individuals who had a concussion history and 11 with individuals who did not have a concussion history. However, because we established data trustworthiness using prolonged exposure, we completed an additional 5 interviews with individuals who had a concussion history and an additional 6 interviews with those who did not have a concussion history.

Table 1 Interview Script^a14 Continued in Next Column

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Once each interview ended, the audio files were sent to a professional transcription company (Rev.com). When the transcripts were returned, the lead investigator (M.L.W.R.) listened to each audio file while reading the transcript to ensure accuracy and redacted any identifying information.

We used a 5-cycle process to analyze the transcripts as described by Anderson,¹⁶ Wertz et al,¹⁷ and Weber Rawlins et al.¹⁴ Cycles 1 and 2 consisted of an initial view into the topic, which was usually completed in an introduction and literature review. Data were collected and summarized in cycle 3. To complete cycle 3, the lead researcher first read the entire data corpus. Five transcripts for each interview script were randomly selected and read by a 4-person research team.¹⁴ The team then met to deliberate and create an initial codebook. During this meeting, the team determined that both interview scripts elicited similar responses and thus could be analyzed together. The lead researcher read all transcripts to code the themes and subthemes as developed from the initial codebook. Eight themes emerged from this process: perceived costs following concussion, cultural differences within squadrons, educational initiatives, the need to disclose, peer encouragement/advocacy, rumors, self-management, and unprompted knowledge. To permit a sufficient analysis of each theme, we focused this article on unprompted concussion knowledge. Cycles 4 and 5 involved relating the findings to other research literature and creating final interpretations. We also counted the frequency of the mentioned signs and symptoms.

As described earlier, data credibility was established through prolonged exposure.¹⁸ We also called on 2 external reviewers to establish dependability and confirmability.^14,18 Finally, we calculated the demographic data using frequencies, means, and SDs.

RESULTS

Overall, we interviewed a total of 34 participants (males = 23, females = 11, age = 19.91 ± 1.14 years).¹⁴ Full participant demographics are provided in Weber Rawlins et al.¹⁴ This article focuses on the theme of unprompted knowledge with the following 5 subthemes: definition, concussion symptoms, “bell-ringer” or “ding” definition, bell-ringer or ding symptoms, and concussion versus bell-ringer or ding.

Concussion Symptoms

Frequencies of concussion signs and symptoms listed by participants are shown in Table 2. The most commonly cited concussion sign and symptom was dizziness (n = 22/34, 64.7%), followed by “can't remember”/“memory loss”/“forgetful” (n = 19/34, 55.9%), and headache (n = 16/34, 47.1%).

Table 2 Concussion Signs and Symptoms Listed by Participants (n = 34) Continued in Next Column

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Bell-Ringer or Ding Symptoms

Frequencies of bell-ringer or ding signs and symptoms listed by participants are given in Table 3. The most common bell-ringer or ding signs and symptoms were dizziness (n = 2/34, 5.9%) and headache (n = 2/34, 5.9%).

Table 3 “Bell-Ringer” or “Ding” Signs and Symptoms Listed by Participants (n = 34)

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DISCUSSION

Overall, the participants' free recall communications reflected a high level of concussion knowledge. They were able to define concussions and bell ringers or dings, listed many common concussion signs and symptoms, and described their perceptions of the difference between concussions and bell ringers or dings. In order to recognize and disclose a concussion, one must understand what a concussion is and that the symptoms being experienced are abnormal. If concussion-education programs can build foundational knowledge regarding what a concussion is, how concussions relate to bell ringers or dings, what the typical signs and symptoms of concussion are, and the importance of reporting any abnormal symptoms, concussion-disclosure rates may increase.

Concussions are defined in many ways.^19–22 The Fifth International Conference on Concussion in Sport defined a concussion as “a traumatic brain injury induced by biomechanical forces.”^22(p2) No matter which definition of concussion is adopted, a common theme is that concussions are injuries that affect brain function caused by biomechanical processes and may or may not involve loss of consciousness. These definitions are useful for clinicians in guiding diagnosis. Participants in this study also had a wide range of concussion definitions. However, numerous cadets' definitions included a mechanism of injury (eg, impact to the head or body) and resulted in some type of abnormal symptoms. A specific definition of a concussion does not necessarily need to be memorized and would likely even be unrealistic, yet it is important for cadets to recognize if what they are experiencing after a possible mechanism of injury could be a concussion. Our research highlighted the concussion definitions used by participants when unprompted; it is important to understand what individuals perceive a concussion is in order for them to recognize the injury and seek medical care.

The most common concussion signs and symptoms are headache and dizziness.²³ These were most frequently noted as signs and symptoms by our participants when describing both concussions and bell ringers or dings. Loss of consciousness was cited as a symptom of a concussion by 26.5% of cadets. In actuality, loss of consciousness only occurred in 9% of reported concussions.²⁴ Therefore, misconceptions regarding loss of consciousness persist, and concussion education should include this information. Other less common symptoms not usually associated with concussions were described as “hearing beeps” or “drainage from the ears.” Recently, Register-Mihalik et al²⁵ found similar results in that cadets most frequently identified headache and pressure in the head as concussion symptoms but less often identified emotional symptoms. Similarly, nearly 12% and 6% of the participants in our sample remarked on “emotional” or “mood” symptoms, respectively, as opposed to 47% who identified headache. It is encouraging that cadets in this study and that of Register-Mihalik et al²⁵ recognized similar concussion signs and symptoms when unprompted and when given a list to choose from, indicating that cadets may answer similarly in a real-world situation when asked about symptoms. Concussion-education interventions should target typical concussion signs and symptoms, including emotional symptoms, and should address “red flags” such as “drainage from the ears” or other signs that would indicate a medical emergency.

Although bell ringer lacks a formal definition, Register-Mihalik et al⁴ found that athletes often used this term to depict a “brief, transient alteration in neurologic function.”^{4(p 647)} Our USAFA cadets also described a bell ringer or ding as brief (eg, “… for a minute …”), and an alteration in neurologic function (eg, “You're disoriented …”). Register-Mihalik et al⁴ stated that even though not all bell ringers or dings are concussions, they at minimum warrant medical attention to determine if a concussion occurred before consideration can be given to returning the athlete to sport. We are the first to examine how cadets themselves define a bell ringer and ding. This information can be used to better relate to patients using targeted educational interventions incorporating their own phrasing and words, especially if this terminology is intended to minimize perceptions of seriousness.

When describing a concussion, health care professionals are encouraged not to use colloquial terms such as a bell ringer or ding, “clearing the cobwebs,” “seeing stars,” etc. However, authors have continued to observe misconceptions regarding concussions and bell ringers or dings in student-athletes.²⁶ Cadets frequently discussed the duration of symptoms in differentiating a concussion and bell ringer or ding, which was noteworthy. Currently, no concussion definition includes a minimum duration of symptoms.^19–22 Given these continuing misconceptions regarding the differences between concussions and bell ringers or dings, clinicians may consider using these terms when asking student-athletes or cadets if they have a concussion history or determining if what they are currently experiencing is a concussion.

Many authors^3,12,13 have commented that an increase in concussion knowledge does not always equal an increase in concussion disclosure. Nonetheless, to recognize a concussion, one must have the foundational knowledge of the signs and symptoms.^2–5 This can be delivered during a concussion-education intervention and should include a wide range of symptoms, especially because numerous concussion signs and symptoms were used to describe a concussion versus a bell ringer or ding. For example, discussing symptoms using cadet terminology such as “feeling loopy” may also be beneficial. Our study highlighted specific educational targets that may be included in concussion-education interventions. This information is the first of its kind using wording and targeted notes from the patient perspective and providing clear evidence for educational concepts and novel educational strategic opportunities. It can be used to supply clinicians with the information needed to approach education and concussion history in a manner that helps cadets identify symptoms if they experience them, not just via a symptom checklist.

Qualitative research does not aim to be generalizable, and our results apply only to those USAFA cadet participants we interviewed. Additionally, we analyzed the data similarly between those with and those without a concussion or bell-ringer or ding history. Future investigators should examine educational interventions that include more colloquial terms to describe a concussion in a broad population. Authors should also explore the mechanisms that may influence a cadet's definition of a concussion or bell ringer or ding, such as peer relationships, previous history, and sport influences.

CONCLUSIONS

Cadets in our sample were able to describe and identify many concussion-related symptoms without cues from the researchers, yet many participants viewed bell ringer and ding in ways that appeared to minimize the seriousness of the injury. Clinicians may use this information to accurately describe concussions, discouraging colloquial terms such as a bell ringer or ding, and discussing the common concussion signs and symptoms and terms found in this study. By highlighting concussion information from the cadet perspective, including common terminology used by cadets, we may better design educational interventions and increase concussion disclosure.