Assessing concussion knowledge among students with varying levels of sports involvement
Abstract
Abstract:Introduction/Purpose: Many medical and physical therapy students indicate that their source of concussion knowledge stems from previous involvement in sports; they also expressed that their education may not prepare them to manage patients with concussions. This study aims to examine how involvement in sports informs concussion knowledge, and to identify gaps in knowledge. Methods: A 17-question Qualtrics survey was distributed to allopathic and osteopathic medical and physical therapy students. Participants were asked to self-report their concussion history, rank their confidence regarding concussion knowledge, answer objective knowledge questions, and assess the degree to which concussion education was taught and its relevance to their field. ANOVA and Chi-square tests were used for analysis. Results: Students with sports participation at the college and professional level demonstrated higher self-ranked concussion knowledge and higher performance on concussion knowledge questions. Our study also showed that deficits in concussion management exist. Conclusion: Students with college or professional sports involvement consistently performed better on survey questions due to their higher rates of personal experience, though the majority of students surveyed did not have this level of sports experience and its accompanying exposure to concussion. Effect sizes for significant results were relatively small, suggesting that practical applications may be limited. Therefore, involvement in sports should not be recognized as an adequate source of concussion education for future clinicians. Based on our results, it can be suggested that all medical and physical therapy students, regardless of sports involvement, will benefit from having a structured curriculum focused on concussion education.
Introduction
After suffering a concussion, patients may experience a myriad of physical, cognitive, and emotional symptoms. Early recognition and appropriate management of a concussion are essential in decreasing these symptoms and long-term complications [1]. Appropriate management requires coordinated care between the patient, physician, physical therapists, and athletic trainers. Ensuring the physician is trained with the most evidence-based practices in concussion care requires an assessment of concussion education in medical training [2].
Healthcare professionals commonly encounter concussions in their practice [3]. However, where their concussion-specific education comes from is unclear [2]. One study shows that 39% of medical students reported that their knowledge of concussions came from somewhere other than their medical education, and only 19% of respondents believed their medical education prepared them to manage concussions as future clinicians [4]. Furthermore, while students may correctly identify possible symptoms of concussion, deficits in knowledge of concussion management exist [5]. The research indicates that concussion education may be incomplete in medical education and that concussion knowledge may be obtained elsewhere.
Involvement in organized sports poses a possible source of concussion education for medical and physical therapy students. While the NCAA requires concussion education for their varsity athletes, there is little research to support if non-varsity or recreational athletes received concussion education through sports participation [6]. There is no legislation that regulates either the content or the delivery of education at any level of sports [6]. The goal of concussion education in sports is to inform athletes of the symptoms of concussion, and the importance of early recognition and reporting [7, 8]. The required knowledge of the clinician exceeds that of athletes, as clinicians will be responsible for decisions on neuroimaging, referrals, therapeutic interventions, and return to activity [6].
Previous involvement in sports also increases the likelihood that students have a personal history of concussions [9]. While previous history may provide anecdotal knowledge, individuals with a history of concussion do not demonstrate improved concussion knowledge [7]. Future clinicians must be properly educated to diagnose and manage concussions in their patients. The purpose of this study is to expand on previous studies focusing on personal history of concussions by examining how involvement with sports informs medical and physical therapy students’ concussion knowledge. Assessing medical students’ knowledge of concussions allows educators to construct curricula to better prepare students to manage concussions in their future practice.
Methods
Respondents
Respondents were recruited by contacting research and student affairs faculty at all allopathic and osteopathic medical, and physical therapy programs in the United States. Survey materials were emailed to the student body of every program. All documentation and study instruments have been approved by Western University of Health Science’s Institutional Review Board.
In total, 1022 students completed the survey. Twenty-nine participants stated that they had never participated in sports, 206 stated that they had participated in sports as a child or in recreational exercise and sports activities, 559 stated that they had participated in sports in high school, and 227 stated that they had participated in sports in college or professionally. A response rate cannot be generated as it is unclear how many students received the survey.
Survey
We used an online Qualtrics survey for this study that included instructions and a consent form. The survey was previously piloted with the parent study conducted by Ekman, Alsky, and Baron [4]. Of the 17 questions, 11 were modified from previous studies done by Boggild and Tator [10], Donaworth et al. [11], and Fraser et al. [12]. Demographic information such as program of study, year in school, and prior sports involvement were added to our survey, unlike the survey used during the previously piloted study done by Ekman, Alsky, and Baron, were also collected. Concussion knowledge related to symptom presentation and management practices was assessed via multiple choice. Participants were allocated a score of either 0 (incorrect) or 1 (correct) per each concussion knowledge question.
Participants were also asked if they felt properly equipped to manage concussions as clinicians, their preference to have more formal concussion education incorporated into their curricula, the relevance of concussion education outside the world of sports, and the relevance of concussion education to the participant’s field of interest. Finally, level of participation in sports was measured using a single item with the following options: 1) I never participated in sports, 2) I only participated in recreational exercise and sports activities, 3) I was actively involved in sports as a child, 4) I was actively involved in sports during high school, 5) I was a collegiate athlete, 6) I was a professional athlete.
Data analysis
Participation in sports as measured by our survey yielded some response categories with relatively low counts. This included those that never participated in sports (n = 29), those that were actively involved in sports as a child (n = 65), and those that were professional athletes (n = 11). Studies suggest that low counts can negatively impact convergence rates, estimation of parameters and standard errors, and statistical power [18, 19]. As a result, the decision was made to consolidate level of sports participation from six to four groups as follows: never participated in sports, participated as a child or in recreational exercise and sports activities, during high school, or collegiately/professionally. Note that due to its distinct nature, the category “never participated in sports” was not combined with any other category.
Two one-way ANOVA’s (using α-value of 0.05) were used to analyze the relationship between the recategorized level of sports participation and self-reported knowledge and actual performance on the concussion test. Pairwise comparisons for ANOVA results were made using Tukey’s HSD to help reduce the possibility of Type 1 error. Eta Squared for each ANOVA was calculated to provide an estimate of effect size.
Chi-square analyses were used to analyze data for the relationship between each knowledge question and level of sports participation and the responses from questions about integration of concussion education in medical and physical therapy curricula, relevance of concussion education outside sports, desire to receive a more formal education on concussions, adequacy of the concussion education already received, and relevance of concussion education to the participant’s field of interest.
Results
Self-ranked knowledge by level of sports participation
Results revealed a significant difference in self-rank by level of sports participation (F = 26.8, p < .001). Eta Squared revealed a small effect size, with only 10.4% of the variance in self-rank knowledge being explained by level of sports participation. A Tukey’s HSD post hoc analysis was used to compare differences between levels of sports participation to minimize possibility of capitalizing on chance.
Results generally showed that those with higher levels of sports participation self-ranked themselves higher on knowledge. Individuals that participated in sports in college or professionally had higher self-ranked scores than those that participated in high school (p < .001), as a child or in recreational exercise and sports activities (p < .001), or never participated in sports (p < .001). Those that participated in sports in high school self-ranked their knowledge higher than those that participated as a child or in recreational exercise and sports activities (p < .001) or never participated in sports (p = .006). Finally, there was no significant difference between those that participated in sports as a child or in recreational exercise and sports activities versus those that never participated in sports (see Figure 1).
Mean concussion knowledge score
Results revealed a significant relationship between level of sports participation and actual performance on the concussion test items (F = 9.5, p < .001). Eta Squared revealed that only 4.8% of the variance in concussion test score can be explained by the level of sports participation. Tukey’s HSD post hoc analyses revealed significant differences between two pairings (see Table 2). Those that participated in sports in college or professionally performed better than those that did so as a child or in recreational exercise and sports activities (p < .001) and college/professionals did better than those that participated in high school (p < .001). No other pairwise comparisons were statistically significant (Table 1).
Knowledge question #1: What is the definition of a concussion?
We looked at participant performance on identifying the correct definition of a concussion using a four-option multiple choice question. The analysis revealed a significant relationship between performance on Question #1 (definition of a concussion) and level of sports participation, χ2(3) = 8.4, p = .039. Z-tests revealed that those that participated in sports in college or professionally (85.0% correct) did better on this item than those that participated as a child or in recreational exercise and sports activities (74.8%). No other pairwise comparisons were statistically significant.
Knowledge question #2: True or false: A loss of consciousness, even briefly, is necessary for a diagnosis of concussion
We looked at participant performance regarding the necessity of loss of consciousness for making the diagnosis of a concussion in a true false format. The analysis revealed a significant relationship between performance on Question #2 (loss of consciousness) and level of sports participation, χ2(3) = 15.5, p < .001. Z-tests revealed that those that participated in sports in college or professionally (96.5%) did significantly better than all other groups (see Table 3). Furthermore, those that participated in high school performed better than those that participated as a child or in recreational exercise and sports activities.
Knowledge question #3: Which of the following is a sign or symptom of a concussion?
We looked at participant performance on identifying all signs or symptoms of a concussion across 11 options. The analysis revealed no significant association between performance on this item and level of sports participation, χ2(3) = 4.650, p = .199.
Knowledge question #4: How many symptoms of a concussion are required to diagnose a concussion?
We looked at participant performance on identifying the correct number of symptoms required to diagnose a concussion across a four-option multiple choice question. The analysis revealed a significant relationship between this item and level of sports participation χ2(3) = 15.684, p = .001 (see Table 3). Z-tests revealed that those that participated in sports in college or professionally (38.8%) did significantly better than those that participated in high school (28.8%) and as a child or in recreational exercise and sports activities (22.3%). Furthermore, those that participated in high school performed better than those that participated as a child or in recreational exercise and sports activities.
Knowledge question #5: What is the appropriate management of a concussion?
We looked at participant performance on identifying the appropriate management of a concussion across 10 different options with various management protocols. The analysis revealed a significant relationship between this item and level of sports participation χ2(3) = 9.0, p = .030 (see Table 3). Surprisingly, Z-tests revealed that those that participated in high school (10.4%) and as a child or in recreational exercise and sports activities (9.2%) did worse than those that never participated in sports (24.1%). No other pairwise comparisons attitudwere statistically significant.
Attitude toward concussion education
Analyses did not reveal significant differences between self-reported level of participation in sports and whether one felt properly equipped to manage concussions as clinicians, their preference to have more formal concussion education incorporated into their curricula, the relevance of concussion education outside the world of sports, and the relevance of concussion education to the participant’s field of interest.
Discussion
Concussion self-rank knowledge
We hypothesized that individuals with higher levels of sport-involvement would have higher levels of knowledge of concussions and thus self-rank their knowledge higher. These predictions were based on previous studies showing that varsity-level athletes are more likely to receive formal concussion education, and subsequently more likely to rank higher self-perceived knowledge of concussions [6]. Higher self-rank knowledge was associated with improved self-awareness among athletes regarding their risk and recognition of concussions, as well as their ability to seek and receive management sooner [8, 13]. When athletes with higher levels of sports involvement have access to athletic trainers, they are more likely to demonstrate improved concussion knowledge [14]. Sports-related concussions are more common than non-sports-related, thus athletes are more likely to personally experience a concussion or witness other athletes with a concussion [15]. Anecdotal knowledge through sports could contribute to higher self-knowledge reporting in our higher sports-level cohort [16, 17].
Sports involvement is inherent to athletes, therefore these previous studies cannot comment on differences in self-rank knowledge between individuals with varying levels of sport-involvement. However, our analysis similarly revealed a significant increase in self-ranked knowledge and actual performance on survey questions between different sport-involvement levels, with college/professional athletes scoring the highest. While sports involvement may increase self-ranked knowledge of concussions, it is not inherent to our population of healthcare professional students, and therefore does not stand as a standardized form of concussion education for students.
Concussion knowledge evaluation
We hypothesized that people who are more involved in sports with concussion exposure would perform better on knowledge questions evaluating concussion presentation, diagnosis and management. Descriptive statistics revealed that participants with higher levels of sports involvement scored higher on our knowledge section. In particular, college or professional athletes scored the highest. In contrast, participants who did not play sports at all or played as a child or in recreational exercise and sports activities scored lower. People who were not involved in sports scored slightly higher than participants who participated as a child or in recreational exercise and sports activities. This anomaly is an exception to our prediction, which is likely due to a small sample size of non-athletes (N = 29) and Tukey’s Post hoc HSD analyses showing p = .996 between the recreational/child and no sports pairing.
There were significant differences between our college/professional with recreational/child and college/professional with high school pairings. This supports our hypothesis that college/professional athletes likely know more about concussions than their counterparts because they may have more personal experiences with concussions. The college/professional athletes theoretically learn more about concussions through their athletic trainers, team physicians, concerned parents, or their own research. Suffering through and recovering from a concussion helps to teach and reinforce knowledge about concussions. In addition, witnessing their own teammates experience concussions can promote learning by being around the teammate during the recovery process [14]. College/professional athletes generally have been playing longer than their counterparts. Thus, they have more opportunities for concussion exposure. A study done by Bernstein et al found that 72% of concussion symptoms were correctly identified in a population of Division I athletes [15]. While higher-level athletes generally demonstrate higher levels of concussion knowledge, Knollman-Porter did not find significant knowledge differences between sports levels [6]. Higher sports levels may result in improved concussion knowledge, though concussion education through sports may not be adequate in educating medical and physical therapy students.
Concussion knowledge questions #1–5
We hypothesized that participants with greater involvement in sports would have a higher percentage correct on each of our five knowledge questions. When evaluating specific knowledge questions, it was observed that participants with greater sports involvement tended to answer questions correctly at a higher rate, especially for questions related to symptom recognition and management. Descriptive statistics revealed that participants with higher levels of sports involvement, such as college or professional athletes, had higher percentages correct on the definition and loss of consciousness regarding concussions. In contrast, participants who did not play sports at all scored the lowest. There were significant differences for pairings involving college/professional athletes.
The majority of participants answered incorrectly on topics regarding the signs, symptoms, diagnosis, and management of concussions, which indicates some knowledge deficits despite sports involvement. Cournoyer and Tipp demonstrated that high school football players had inadequate knowledge for recognizing symptoms of a concussion despite their experience and sports background. This study attributed their lack of knowledge to poor quality of education regarding concussion symptoms and management [17]. Descriptive statistics showed no significant difference in percentage corrects among the four sports levels regarding concussion signs and symptoms. Participants with higher levels of sports involvement had a higher percentage correct involving concussion diagnosis. College or professional athletes scored the highest. In contrast, participants who did not play sports scored the lowest.
Concussion management displayed an exception to our hypothesis, where those that never participated in sports performed better. Given that concussion management was also the most difficult topic, the item may not have discriminated well between high and low performers. This result notwithstanding, analyses of individual items support our hypothesis that college/professional athletes are likely more knowledgeable about concussions. However, it should be noted that concussion education remains varied and unstandardized across the nation despite state-based legislation being implemented [16]. This further emphasizes the importance of providing standardized concussion education for health professional students.
Limitations
There are several limitations to the study that should be acknowledged. The data acquired is self-reported by respondents, which can lead to social-desirability bias. The sample was composed of collegiate-level educated individuals meaning the generalizability to a general population is limited. The survey was distributed to students of the participating programs, which may introduce response bias. Those who chose to participate may have had a higher interest or knowledge in the topic of concussion or in sports compared to non-participants, leading to an overestimation of these two measurements. Furthermore, while the authors are confident that our measurement of level of sports participation was valid, the decision to consolidate some of the response choices after data collection may require further study.
Our study is also not immune to confounding variables. It was not specifically asked whether or not participants were involved in contact versus non-contact sports. Participants in contact sports could potentially have more exposure to concussions versus their counterparts in non-contact sports where collisions are less likely to occur. The role of interest in concussion is another confounder, as participants with higher levels of sports involvement could be more interested in learning about concussions versus their counterparts with lower levels of sports participation.
The study utilized a single online survey as the assessment tool, which may not capture the full range of concussion knowledge and clinical management. Other methods, such as practical examinations or clinical simulations, could provide a more comprehensive evaluation of participants’ abilities. Demographic data was not originally included in the first iteration of the study done by Ekman, Alsky, and Baron [4]. It was only added for our study, the second rendition, where we looked at the performance of MD, PT, and DO students.
Another limitation of the study is the lack of in-depth regression analysis. Since demographic information was incomplete for the majority of our participants, our study lacked sufficient data to support this type of analysis. Based on the design of our study, we do not have the data to support directionality. It cannot be ascertained whether or not higher levels of sports participation resulted in higher levels of concussion knowledge or vice versa. Finally, it is worth repeating that effect sizes for significant results were relatively small, suggesting that practical applications may be limited.
Future directions
The findings of this study provide insights into the relationship between sports involvement and concussion knowledge among medical and physical therapy students. However, there are several areas that warrant further investigation and future directions in research. Expanding the study to non-US medical and physical therapy students could allow us to evaluate how concussion education varies among different countries.
Tracking students’ knowledge and skills development throughout their educational journey and professional practice could reveal any changes or improvements in their concussion management abilities. Comparative studies can be conducted to evaluate the outcomes of various educational approaches, such as incorporating formal concussion education into medical and physical therapy curricula, providing specialized training programs, or utilizing technology-based learning tools. Examining the retention of knowledge and the application of learned skills in clinical settings would help identify the most effective educational strategies.
Developing standardized guidelines or recommendations for concussion education in medical and physical therapy curricula is important to ensure consistent and comprehensive training for future healthcare professionals [9]. Future research can focus on establishing a consensus among educators, professional organizations, and governing bodies regarding the essential components, competencies, and best practices for concussion education.
Conclusion
Our study assessed the relationship between involvement in sports and various aspects of concussion knowledge in medical and physical therapy students. The findings revealed that participants with higher levels of sports involvement tend to have higher self-rank knowledge of concussions.
Our results highlight the need for improved concussion education in medical and physical therapy curricula. Despite the overall higher knowledge levels among participants with sports involvement, the knowledge scores across all groups were relatively low, indicating a potential gap in their education regarding concussions. This suggests that concussion education provided in medical and physical therapy programs may not be comprehensive enough to adequately prepare future clinicians for managing concussions.
These findings emphasize the importance of incorporating more formal and comprehensive concussion education in medical and physical therapy curricula. By enhancing the education provided to students, educators can better equip future clinicians with the necessary knowledge and skills to effectively diagnose and manage concussions in their patients.
Electronic Supplementary Materials
The following electronic supplementary material is available with this article at https://doi.org/10.1024/2674-0052/a000067
References
1 Selected issues in sports-related concussion (SRC/Mild Traumatic Brain Injury) for the team physician: a consensus statement. Br J Sports Med. 2021;55:1251–61. https://doi.org/10.1136/bjsports-2021-104235
2 Multidisciplinary concussion management: a model for outpatient concussion management in the acute and post-acute settings. J Head Trauma Rehab. 2019;34:375–84. https://doi.org/0.1097/HTR.0000000000000527
3 . Physician management of sport-related concussions at the collegiate level. Athl Train Sports Health Care. 2010;2(5):227–34. https://doi.org/10.3928/19425864-20100630-03
4 . Concussion education in medical school. Acad Psychiatry. 2021;45:242–43. https://doi.org/10.1007/s40596-021-01405-2
5 . Concussion education in medical students studying in Scotland: an assessment of knowledge and future needs. Brain Injury. 2022;36(9):1196–203. https://doi.org/10.1080/02699052.2022.2115139
6 . A preliminary examination of concussion knowledge by collegiate athletes and non-athletes. Am J Speech Lang Pathol. 2018;27(2):778–95. https://doi.org/10.1044/2018_AJSLP-17-0108
7 . Factors related to concussion knowledge, attitudes, and reporting behaviors in US high school athletes: a systematic review. J School Health. 2022;92:406–17. https://doi.org/10.1111/josh.13140
8 . Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. J Athl Train. 2013;48(5):645–53. https://doi.org/10.4085/1062-6050-48.3.20
9 American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15–26. https://doi.org/10.1136/bjsports-2018-100338
10 . Concussion knowledge among medical students and neurology/neurosurgery residents. Can J Neurol Sci. 2012;39(3):361–8.
11 . Is current medical education adequately preparing future physicians to manage concussion: an initial evaluation. Phy Sportsmed. 2016;44(1):1–7.
12 . Cross-sectional comparison of spiral versus block integrated curriculums in preparing medical students to diagnose and manage concussions. BMC Med Educ. 2019;19(1):17.
13 . Mandated high school concussion education and collegiate athletes’ understanding of concussion. J Athl Train. 2017;52(7):689–97. https://doi.org/10.4085/1062-6050-52.3.08
14 . Knowledge of concussion and reporting behaviors in high school athletes with or without access to an athletic trainer. J Athl Train. 2017;52(3):228–35. https://doi.org/10.4085/1062-6050-52.1.07
15 . Predictors of collegiate student-athletes’ concussion-related knowledge and behaviors. Can J Neurol Sci. 2019;46(5):575–84. https://doi.org/10.1017/cjn.2019.76
16 . Lifetime prevalence of self-reported concussion among adolescents involved in competitive sports: a national U.S. study. J Adolesc Health. 2019;64:272–5. https://doi.org/10.1016/j.jadohealth.2018.08.023
17 . Concussion knowledge in high school football players. J Athl Train. 2014;49(5):654–8. https://doi.org/10.4085/1062-6050-49.3.34
18 . Collapsing scale categories: comparing the psychometric properties of resulting scales. Pract Asses Res Eval. 2020;25(6). https://doi.org/10.7275/17315702
19 . Collapsing categories is often more advantageous than modeling sparse data: investigations in the CFA framework. Struct Equ Model. 2020;28(2):237–49. https://doi.org/10.1080/10705511.2020.1803073
