A Preliminary Examination of Concussion Knowledge by Collegiate Athletes and Non-Athletes

Kelly Knollman-Porter; Jessica Brown; Madelaine Flynn

doi:10.1044/2018_AJSLP-17-0108

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Research Article | May 03, 2018

A Preliminary Examination of Concussion Knowledge by Collegiate Athletes and Non-Athletes

Kelly Knollman-Porter, Jessica Brown, and Madelaine Flynn

Author Affiliations & Notes

Article Information

American Journal of Speech-Language Pathology, May 2018, Vol. 27, 778-795. doi:10.1044/2018_AJSLP-17-0108

History: Received July 18, 2017; Revised November 4, 2017; Accepted January 3, 2018

Purpose Concussions affect various populations, including collegiate athletes and non-athletes. The purpose of this study was to compare collegiate varsity athletes, recreational athletes, and non-athletes' knowledge of concussion definition, symptoms, and support services available following injury. Preferred method of concussion education delivery was also examined.

Method We surveyed 306 current college students using an online survey system. The survey included free recall and forced-choice question formats. Quantitative analyses were used to analyze results and compare responses among groups.

Results Collegiate athletes and non-athletes demonstrate incomplete knowledge of concussion definition, related symptoms, and professionals involved in postinjury management. Varsity athletes rated self-knowledge of concussion parameters significantly higher than the other groups (p < .001), though few significant differences in actual knowledge levels were observed. Overall, respondents reported having the highest preference for concussion education delivered by medical professionals.

Conclusion Knowledge concerning concussion is incomplete in the collegiate population. Varsity athletes' exposure to formal education did not result in higher knowledge levels compared with other groups. Further examination of concussion educational delivery models' effect on change in concussion-related behavior in this population is warranted.

Concussions can lead to both short- and long-term somatic, socioemotional, and cognitive deficits (Jotwani & Harmon, 2010; King, Brughelli, Hume, & Gissane, 2014; McCrea et al., 2003). For collegiate students—both athletes and non-athletes—postinjury symptoms, such as headache, confusion, and/or decreased attention, can negatively impact academic task performance (Wasserman, Bazarian, Mapstone, Block, & van Wijngaarden, 2016). Recognition of concussion-related symptoms is necessary before individuals can seek services for management of temporary and/or persistent postinjury sequelae.

In order to educate young adults on injury identification, concussion educational methods and materials should be theory driven and geared toward the target audience (Kurowski, Pomerantz, Schaiper, Ho, & Gittelman, 2015). Even though collegiate varsity athletes receive mandated concussion education (National Collegiate Athletic Association [NCAA], 2014), some suggest that traditional educational methods appear ineffective in enacting change in outcomes, such as intent to report symptoms to an athletic or health care professional (Kurowski et al., 2015). Additionally, recreational athletes and non-athletes may receive little or no formal education addressing the symptoms experienced following injury even though they are also at risk for concussion. Therefore, understanding the perspectives from both collegiate athletes and non-athletes regarding their current knowledge of concussion may guide future educational and management efforts by medical professional leading to more effective and efficient postinjury care.

The Nature of Concussions

Concussion is defined as a mild brain injury caused by direct or indirect biomechanical forces on the brain resulting in transient disturbances in neurological functioning (Harmon et al., 2013). In the general public, brain injury rates are highest in children and older adolescents (i.e., 15 to 24 year olds; Faul, Xu, Wald, & Coronado, 2010) due to falls, motor vehicle accidents, and participation in sports. By the age of 24 years, approximately 5% of the population will have sought medical care in an emergency room setting due to brain injury (Center for Disease Control, 2016). However, secondary to widespread underreporting, rates of concussion in the United States may be even higher. In fact, in a study by Brown et al. (2015), approximately 28% of college-aged students reported experiencing a concussion or brain injury at some point in their life with 10% reporting chronic postinjury health symptoms (Hux, Brown, & Lambert, 2016). This self-reported prevalence of concussion in the general public is over five times the documented emergency room care data, thus further substantiating the need for further education and injury identification.

Individuals participating in sports at any level run the risk of sustaining head injuries. Recent figures estimate that between 1.6 and 3.8 million concussions occur annually in the United States during sport-related activities (Harmon et al., 2013). Collegiate students are at risk of sustaining sports-related concussions in varsity-level athletics and in structured (e.g., club) and informal recreational-level sports (Musille, 2016). While approximately 460,000 student athletes participate in NCAA varsity athletics in the United States each year, as many as 2 million student athletes participate in club sports annually (NCAA, n.d.; Pennington, 2008). Both collegiate varsity and recreational athletes participating in contact sports (e.g., football, ice hockey, rugby, and boxing) are at a heightened risk of concussion as compared with athletes of noncontact sports. Nonetheless, all athletes are susceptible to injury (Harmon et al., 2013; Powell, 2001).

Even college students who do not participate in organized or recreational sports activities are at risk for concussion. Non-sport-related concussion can occur during activities of everyday living, falls, acts of violence, and traffic- or work-related accidents. Although the underlying circumstance causing the concussion is different, the symptoms associated with the injury can negatively impact a student's ability to return to academic and work-related activities. In addition, this population does not have access to immediate support personnel (e.g., athletic trainers and team physicians) who can educate and provide recommendations for injury management following concussion.

Concussion Knowledge and Education

Misconceptions regarding the definition and symptoms associated with concussion exist both for athletes and members of the general public (Fedor & Gunstad, 2015; Kurowski et al., 2015; Register-Mihalik et al., 2013). Although evidence suggests that collegiate varsity athletes identify a greater number of somatic and cognitive postconcussive symptoms than collegiate non-athletes, they fail to consistently recognize possible emotional symptoms from head injury (e.g., feeling irritable, depressed, or easily angered; Fedor & Gunstad, 2015). The general public's knowledge of concussion also appears to be limited, with misconceptions regarding identification of basic concussive symptoms (e.g., light sensitivity, noise sensitivity, and nausea or vomiting), as well as understanding under what circumstances to seek formal evaluation and treatment (Fedor & Gunstad, 2015; McKinlay, Bishop, & McLellan, 2011).

It is uncertain what factors may impact an individual's decision on whether or not to seek out medical treatment following possible concussion. A guiding factor could be one's knowledge regarding concussions. One important contributor to knowledge is the method used to educate the population of interest; however, adjustments made to educational content and delivery on the basis of those unique needs is suggested (Kroshus, Daneshvar, Baugh, Nowinski, & Cantu, 2013; Provvidenza et al., 2013).

Varsity Athletes

In 2010, the NCAA created Concussion Policy and Legislation stating that all institutions in the NCAA must maintain a concussion management plan that includes, among other requirements, yearly concussion education for varsity athletes (NCAA, 2013). Though annual education is required, the NCAA does not regulate the content or delivery method of preseason educational materials, raising concerns regarding the effectiveness of preseason education across universities (Baugh et al., 2014).

A most reliable and effective method of education for varsity athletes continues to be examined, though there is concern that traditional approaches are ineffective in enacting change in behavior related to concussion (Kurowski et al., 2015). For example, though lecture-based methods may improve knowledge of concussion immediately following teaching, evidence suggests that intent to report concussion symptoms to a professional is not impacted by a didactic preseason educational session (Kroshus et al., 2013; Kurowski et al., 2015). Furthermore, educational preferences of college student athletes are largely unknown, though collegiate varsity hockey players have indicated a preference for the use of videos (Kroshus et al., 2013).

Recreational Athletes and Non-Athletes

Currently, concussion education of recreational athletes and non-athletes is not considered in empirical research or within legislative efforts, potentially due to decreased formal monitoring of head injuries in these populations. Some universities have a concussion protocol in place for recreational athletics, whereas others do not (Linsenmeyer, 2017). Similarly, non-athletes have no concussion education requirement and must rely on personal knowledge of head injury or independently seek out publicly available information. McKinlay et al. (2011) reported confusion in the “general public” concerning knowledge of common misconceptions about concussion (e.g., concussions result only from an insult directly to the head). Knowledge of the definition of concussion is uncertain in the collegiate population given the focus on symptom identification in the extant literature (Cournoyer & Tripp, 2014; Fedor & Gunstad, 2015). Additionally, little is known about how current knowledge of concussion drives behavioral choices made during physical activity or postconcussion in this population.

Professionals Involved in Concussion Management

Concussion recognition, diagnosis, and subsequent management is largely dependent upon collaboration between the injured individual and the concussion management team. For college students, this team can consist of health care professionals (e.g., physicians [McCrory et al., 2013 ], athletic trainers [Broglio et al., 2014 ], physical therapists [Alsalaheen et al., 2010 ], and speech-language pathologists [SLPs; Knollman-Porter, Constantinidou, & Marron, 2014 ]), academic professionals (e.g., professors and academic advisors), and social supporters (e.g., family members and friends).

All team members provide a unique perspective to concussion management. Physicians implement pharmacological symptom management (Petraglia, Maroon, & Bailes, 2012), provide referrals for neuroimaging, and make final return-to-play decisions for injured athletes (Knollman-Porter et al., 2014), whereas athletic trainers can provide initial evaluation of athletes immediately following injury and ongoing monitoring of symptoms (Broglio et al., 2014), and physical therapists address postinjury vestibular deficits (Alsalaheen et al., 2013). Previous literature has highlighted the importance of an SLP as a member of the larger concussion management team (e.g., Duff et al., 2002; Knollman-Porter et al., 2014; Sohlberg & Ledbetter, 2016). SLPs can provide neurocognitive assessment, implementation of restorative and compensatory techniques for persistent symptoms, and psychosocial support, including postinjury education and counseling at any educational level (Knollman-Porter et al., 2014; Sohlberg & Ledbetter, 2016). Communication and collaboration between team members is essential for effective concussion management, as all members have skills and experience in different areas. Though evidence suggests that knowledge of concussion symptoms remains limited in the collegiate population, the extent of knowledge of support services following injury is unknown.

Current Study

Some information regarding knowledge of concussion definition and symptoms among collegiate varsity athletes is known. Conversely, very little is known with regard to concussion knowledge in collegiate recreational athletes and non-athletes, a population that does not typically receive regular concussion education or postinjury management support. Therefore, understanding the current knowledge base and the effect of that knowledge on behavior may help drive future education and postinjury management protocols. Current research also has yet to address college students' ability to recall and recognize professionals involved in concussion management. Such knowledge may impact the likelihood of individuals to report postinjury symptoms to a professional (Bramley, Patrick, Lehman, & Silvis, 2012). This, in turn, is necessary to promote effective symptom management and treatment to decrease the risk of repeated or prolonged deficits (Chrisman, Quitiquit, & Rivara, 2013).

The purpose of the current preliminary study was to compare knowledge of the definition of and symptoms associated with concussion and available support services available postinjury of collegiate varsity athletes, recreational athletes, and non-athletes from two midwestern Division 1 universities. A secondary aim was to ascertain the education formats preferred by collegiate respondent groups when receiving concussion information. The authors proposed the following research questions:

What is the difference between collegiate varsity athletes, recreational athletes, and non-athletes on knowledge of concussion definition and symptom identification?
Do collegiate varsity athletes, recreational athletes, and non-athletes differ on knowledge of available concussion support services?
What method of concussion education is most preferred by collegiate varsity athletes, recreational athletes, and non-athletes?
How does previous concussion education affect behaviors during physical activity?

Method

Respondents

Recruitment/Selection

Participant recruitment occurred at two large, midwestern Division 1 universities from two different athletic conferences. Varsity and club sport athletes representing all sports, academic levels, genders, and races at the respective universities received the same recruitment materials electronically and via flier and had equal opportunity to participate in the survey. In total, over 1,500 athletes received recruitment information. Recruitment fliers were also posted at key locations on campus that both athletes and non-athletes frequent (e.g., student health center), and recruitment events were held at the university recreational center and student union. All methods and procedures were approved by the institutional review boards at both universities prior to recruitment.

A total of 306 collegiate students participated in this study. Respondents included 206 women and 99 men—one respondent selected not to answer this question—and a mean age of 20.08 years old (range = 17–46; SD = 2.63). A variety of ethnic and racial groups comprised the sample, including Asian (1.62%), American Indian or Alaska Native (0.97%), Black or African American (1.30%), and Caucasian (90.30%). Respondent ethnicity was representative of the population characteristics at each participating institution. Respondents included individuals from multiple graduating classes (i.e., 63 freshmen, 92 sophomores, 62 juniors, 68 seniors, 14 graduate-level students, and seven respondents who selected “prefer not to answer”).

The sample included 60 individuals self-identifying as varsity athletes, 190 recreational athletes, and 56 non-athletes. The sample population showed representation of 12 varsity sports (e.g., baseball/softball, basketball, football, soccer, and swimming/diving) and 30 recreational sports (e.g., broomball, football, hockey, lacrosse, rugby, and wrestling).

Survey

The current study utilized a survey research method made available to respondents via an online link. Survey research generally gives greater flexibility to researchers than experimental designs, by allowing the probing of respondents regarding perceptions and definitions of concepts rather than committing to operational definitions in advance (Babbie, 2011). Online surveys in particular allow for participation of individuals hesitant to meeting face-to-face (Wright, 2005). Online surveys are also convenient for both researchers and respondents, as researchers are able to instantaneously collect anonymous electronic data, and respondents have the ability to complete the survey at their leisure (Buchanan & Hvizdak, 2009). Use of an online survey was particularly beneficial for recruitment of the population of interest in this study, as collegiate students are generally well-versed in computer and Internet practices (Salaway, Borreson Caruso, & Nelson, 2008).

We utilized an electronic online survey developed through Qualtrics^©. The survey contained written instructions and an online consent form, which participants could voluntarily complete at their convenience. The electronic survey included 60 total multiple-choice, Likert-type, ranking, and free recall questions. All respondents' responses were included in the analysis of data even if participants chose to not answer all questions. Table 1 provides a breakdown of survey sections and subtopics. Sample questions from the survey, which directly relate to the context of this study (e.g., concussion knowledge and education), are located in the Appendix. To enhance readability, conditional logic was removed from the sample provided.

Table 1. Summary of survey sections and sample question topics.

Topics	No. of questions	Question types	Sample questions
Demographic information	15	• Multiple choice	• Age
Demographic information	15	• Free recall	• Level of athletic participation
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of signs/symptoms associated with concussion
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of the definition of concussion
Concussion definition knowledge	3	• Free recall	• Recall of concussion definition in respondents' own words
Concussion definition knowledge	3	• Multiple choice	• Definition of concussion provided multiple choice options
Concussion symptom knowledge	2	• Free recall	• Recall of concussion symptoms in respondents' own words
Concussion symptom knowledge	2	• Multiple choice	• Selection of relevant symptoms from provided list
Related professionals knowledge	2	• Free recall	• Recall of concussion-related professionals in respondents' own words
Related professionals knowledge	2	• Multiple choice	• Selection of related professionals from provided list
Concussion education experiences	6	• Multiple choice	• Previous methods of concussion education
		• Ranking	• Ranking of concussion educational methods
		• Likert-type

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Table 1. Summary of survey sections and sample question topics.

Topics	No. of questions	Question types	Sample questions
Demographic information	15	• Multiple choice	• Age
Demographic information	15	• Free recall	• Level of athletic participation
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of signs/symptoms associated with concussion
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of the definition of concussion
Concussion definition knowledge	3	• Free recall	• Recall of concussion definition in respondents' own words
Concussion definition knowledge	3	• Multiple choice	• Definition of concussion provided multiple choice options
Concussion symptom knowledge	2	• Free recall	• Recall of concussion symptoms in respondents' own words
Concussion symptom knowledge	2	• Multiple choice	• Selection of relevant symptoms from provided list
Related professionals knowledge	2	• Free recall	• Recall of concussion-related professionals in respondents' own words
Related professionals knowledge	2	• Multiple choice	• Selection of related professionals from provided list
Concussion education experiences	6	• Multiple choice	• Previous methods of concussion education
		• Ranking	• Ranking of concussion educational methods
		• Likert-type

Self-perception knowledge questions were based on a 5-point Likert-type scale, with respondents providing a rating ranging from 1 to 5 stars. Respondents also provided a free recall definition of concussion and list of symptoms using their own words. Respondents then selected perceived symptoms associated with concussion on the basis of both historic and recent research, including somatic (e.g., headache), socioemotional (e.g., depression), and cognitive symptoms (e.g., decreased concentration; Jotwani & Harmon, 2010; Kennedy, Krause, & Turkstra, 2008; Krause & Richards, 2014; McAllister & Arciniegas, 2002; McCrea, Kelly Randolph, Cisler, & Berger, 2002; Webb & Barth, 2003; World Health Organization, 2004). Four of the 38 frequently cited symptoms were foils (e.g., deafness). An additional 5-point Likert-type scale was used when asking respondents to rate the quality of any previous concussion education, with a rating of 1, indicating extremely low quality education, and a rating of 5, indicating extremely high quality education. Respondents also ranked their concussion education preferences with a 1, indicating the most preferred method, and a 7, indicating the least preferred method.

Data Analysis

We utilized an alpha level of .05 to identify statistically significant results. General descriptive statistics allowed for examination of respondent demographic information, knowledge of concussion definition, symptoms, related professionals, and concussion education preferences. We computed a series of analyses of variance (ANOVAs) and Pearson chi-square tests to identify potential differences between the three groups' category responses. We completed Tukey's honestly significant difference (HSD) post hoc analyses to determine the nature of significance between group differences as appropriate.

A member of the research team and a trained graduate assistant independently rated the three free recall questions. The authors used Harmon et al.'s (2013) definition of concussion as a standard by which to judge responses to the free recall of concussion definition. A researcher and trained graduate student rated responses on the basis of inclusion of the following parameters: concussion is a (a) brain injury (b) caused by biomechanical forces (c) with short-term impairment of cognitive, somatic, or emotional symptoms. Respondents were not expected to use this exact terminology in provided definitions. An example of an acceptable answer provided by a respondent is as follows:

A concussion is an injury to the head that causes the brain to shake inside the skull, which can result in various side-effects [sic] including loss of consciousness, dizziness, and more.

We counted the individual and total number of parameters included within each response. Calculation of percent agreement between raters determined interrater reliability, with agreement averaging at 98% for recall of concussion symptoms, 98% for definition of concussion, and 96% for recall of professionals involved in concussion management. Intrarater reliability was determined with 100% agreement obtained.

The unbalanced sample across analyses is likely the result of the survey's conditional logic mechanisms. Survey logic was implemented, such that participants only responded to particular questions on the basis of previous responses. Analyses of survey items in the initial stages of the online questionnaire show a sample of 306 respondents, whereas items in the final stages include a sample of 280 respondents. Furthermore, given this conditional survey logic, 149 individuals completed 90% or more of the survey, whereas the majority of remaining respondents completed between approximately 50% and 89%. This resulted in the majority of participants (i.e., 77%) completing the survey in 16 min or less.

Results

Concussion Definition Knowledge

Self-Perception

We completed a one-way ANOVA to examine differences in self-perception of concussion definition knowledge among varsity athletes (range = 2.00–5.00, M = 4.05, SD = 0.75), recreational athletes (range = 1.00–5.00, M = 3.72, SD = 0.98), and non-athletes (range = 1.00–5.00, M = 3.21, SD = 1.02). The one-way ANOVA revealed a significant main effect across conditions, F(2, 302) = 11.33, p < .001. Tukey's HSD post hoc analyses were conducted given the statistically significant ANOVA. Analyses revealed that varsity athletes rated themselves significantly higher than both recreational athletes (p = .049) and non-athletes (p < .001) in knowledge of definition of concussion. Similarly, recreational athletes rated themselves significantly higher than non-athletes (p = .002).

Free Recall

When asked to provide a definition of concussion in their own words, 69.28% (N = 212) of respondents indicated that concussion is considered a brain injury, 66.01% (N = 202) of respondents included concussion resulting from biomechanical forces, and 20.59% (N = 63) of respondents provided relevant symptoms within the concussion definition. Additionally, 3.59% (N = 11) of respondents included all three parameters as a part of the definition of concussion (e.g., “A concussion is when you get hit in the head and your brain gets jostled around in your skull. This can be accompanied by headache, blurred vision or feeling your bell rung.”), 56.69% of respondents (N = 174) included two parameters (e.g., “a blow to the head that results in the brain striking the skull.”), 32.03% of respondents (N = 98) included one parameter (e.g., “Hitting your head really hard.”), and 7.52% of respondents (N = 23) did not include any of the targeted parameters within concussion definitions (e.g., “I have no idea.”).

Forced Choice

Given multiple choice options, 69.28% (N = 203) of respondents correctly identified the definition of concussion. A chi-square test determined that there was a significant difference between the groups, χ²(8, N = 293) = 15.88, p = .044. Post hoc chi-square analyses with a Bonferroni-corrected p value of .003 to reduce the risk of Type I error revealed non-athletes selected an incorrect response, “an injury to the soft structures of the brain causing brief memory loss,” more frequently than the other groups (p < .001). No other significant differences were found between groups. Descriptive statistics also revealed that 96.26% (N = 283) of respondents correctly selected “false” given a statement that an individual must lose consciousness in order to be diagnosed with a concussion. No significant differences existed between groups, χ²(6, N = 294) = 8.24, p = .221.

Knowledge of Concussion Symptoms

Self-Perception

In order to examine self-perceptions of concussion symptom knowledge, we completed a one-way ANOVA to compare varsity athletes (range = 3.00–5.00, M = 4.23, SD = 0.68), recreational athletes (range = 1.00–5.00, M = 3.78, SD = 0.98), and non-athletes (range = 1.00–5.00, M = 3.34, SD = 1.10). The ANOVA revealed a significant main effect across conditions, F(2, 301) = 12.96, p < .001. Tukey's HSD post hoc analyses again revealed varsity athletes rating themselves as having better knowledge than both recreational athletes (p = .004) and non-athletes (p < .001), as well as recreational athletes rating themselves higher than non-athletes (p = .006).

Free Recall

When asked to list symptoms associated with concussion, respondents most frequently reported somatic and cognitive symptoms, such as headache (70.26%, N = 215), dizziness (56.54%, N = 173), memory loss (46.73%, N = 143), and nausea (40.52%, N = 124). Less frequently recalled symptoms included being mentally foggy (7.84%, N = 24), change in emotional state (7.53%, N = 23), and change in personality (1.96%, N = 6).

Forced Choice

Descriptive statistics revealed that 73.13% (N = 215) of respondents correctly identified “headache” as the most commonly experienced symptom following concussion given four options. No significant difference existed between athletic levels, χ²(8, N = 294) = 9.39, p = .310. Descriptive statistics revealed that 98.30% (n = 289) of respondents recognized that concussion symptoms can negatively impact academic and work performance. No significant differences existed between athletic levels, χ²(4, N = 294) = 3.27, p = .514.

When provided a list of 38 symptoms, respondents most frequently identified the following symptoms as being related to concussion: headache, concentration problems, dizziness, problem focusing eyes, and balance/coordination problems. Respondents least frequently selected the following symptoms, included as distractor items, as being related to concussion: unusual hunger, deafness, blindness, and panic attacks. See Table 2 for frequencies and percentages of the 20 most frequently identified symptoms.

Table 2. Percentages of the 20 most frequently identified symptoms per participant group.

Concussion symptoms	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Headache	83.3	91.1	94.6
Concentration problems	83.3	89.5	85.7
Dizziness	78.3	85.8	92.9
Problem focusing eyes	75.0	86.8	91.1
Balance/coordination problems	83.3	86.3	82.1
Slow thinking	76.7	84.7	83.9
Light/sound sensitivity	80.0	81.6	89.3
Confusion to your situation	75.0	82.6	82.1
Problems paying attention at school or work	70.0	78.9	82.1
Pain	73.3	72.6	82.1
Anterograde amnesia	63.3	72.6	87.5
Retrograde amnesia	70.0	75.3	64.3
Difficulty multitasking	63.3	70.0	75.0
Difficulty solving problems	65.0	70.0	69.6
Difficulty reading	61.7	68.4	75.0
Excessive fatigue	66.7	68.9	67.9
Planning/organization problems	61.7	70.5	62.5
Difficulty learning new information	55.0	67.4	60.7
Irritability	61.7	60.0	73.2
Sleeping more than usual	53.3	59.5	66.1

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Table 2. Percentages of the 20 most frequently identified symptoms per participant group.

Concussion symptoms	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Headache	83.3	91.1	94.6
Concentration problems	83.3	89.5	85.7
Dizziness	78.3	85.8	92.9
Problem focusing eyes	75.0	86.8	91.1
Balance/coordination problems	83.3	86.3	82.1
Slow thinking	76.7	84.7	83.9
Light/sound sensitivity	80.0	81.6	89.3
Confusion to your situation	75.0	82.6	82.1
Problems paying attention at school or work	70.0	78.9	82.1
Pain	73.3	72.6	82.1
Anterograde amnesia	63.3	72.6	87.5
Retrograde amnesia	70.0	75.3	64.3
Difficulty multitasking	63.3	70.0	75.0
Difficulty solving problems	65.0	70.0	69.6
Difficulty reading	61.7	68.4	75.0
Excessive fatigue	66.7	68.9	67.9
Planning/organization problems	61.7	70.5	62.5
Difficulty learning new information	55.0	67.4	60.7
Irritability	61.7	60.0	73.2
Sleeping more than usual	53.3	59.5	66.1

Chi-square analyses revealed significant differences between the three groups on the following symptoms: problems focusing eyes, χ²(2, N = 306) = 6.92, p = .031; difficulty writing, χ²(2, N = 306) = 7.81, p = .020; and anterograde amnesia, χ²(2, N = 306) = 8.90, p = .012. A series of 2 × 2 chi-squares were run to determine individual differences between groups. Both recreational athletes, χ²(1, N = 250) = 4.76, p = .029, and non-athletes, χ²(1, N = 116) = 5.24, p = .022, identified problems focusing eyes as symptoms of concussion more frequently than varsity athletes. Additionally, varsity athletes were less likely to associate difficulty writing with concussion than recreational athletes, χ²(1, N = 250) = 6.63, p = .010, and non-athletes, χ²(1, N = 116) = 5.81, p = .016. Varsity athletes also associated anterograde amnesia with concussion less frequently than non-athletes, χ²(1, N = 116) = 9.02, p = .003. No other significant differences existed between athletic levels.

Knowledge of Support Services

Self-Perception

A one-way ANOVA was utilized to compare varsity athletes (range = 1.00–5.00, M = 3.25, SD = 1.27), recreational athletes (range = 1.00–5.00, M = 2.77, SD = 1.22), and non-athletes (range = 1.00–5.00, M = 2.17, SD = 1.13) on perceived knowledge of support services following injury. The ANOVA revealed a main effect across conditions, F(2, 300) = 16.71, p < .001. Tukey's HSD post hoc analyses again revealed varsity athletes rating themselves as having better knowledge than both recreational athletes (p = .021) and non-athletes (p < .001), as well as recreational athletes rating themselves higher than non-athletes (p = .004).

Free Recall

When asked to list all professionals involved in management of concussion, respondents most frequently identified related professionals, such as general doctors (77.12%, N = 236), athletic trainers (48.69%, N = 149), and neurologists (25.48%, N = 79). Less frequently identified members of concussion management included friends/family members (8.17%, N = 25), teachers (2.94%, N = 9), occupational therapists (2.94%, N = 9), and SLPs (2.94%, N = 9). Of note, 26 respondents (8.50%) responded “I don't know” or gave no response.

Forced Choice

Descriptive statistics also revealed that, when provided a list of 22 potential options, respondents most frequently recognized a primary care/family medicine doctor and an athletic trainer as professionals involved in concussion management. See Table 3 for percentages per participant group of all professionals listed.

Table 3. Percentage of professionals identified per participant group.

Concussion management professionals	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Primary care/family medicine doctor	73.3	88.4	85.7
Athletic trainer	81.7	84.7	80.4
Emergency room doctor	73.3	83.2	91.1
Neurologist	48.3	72.1	73.2
Coach	68.3	68.4	62.5
Psychologist or neuropsychologist	60.0	67.4	69.6
Nurse	48.3	66.3	73.2
Physical therapist	31.7	52.6	51.8
Occupational therapist	23.3	32.1	46.4
Psychiatrist	38.3	28.9	33.9
Teacher	20.0	30.5	32.1
Academic advisor	25.0	31.1	23.2
Speech-language pathologist	18.3	25.8	37.5
Optometrist/ophthalmologist	13.3	27.4	23.2
Recreational therapist ^a	8.3	22.1	26.8
Chiropractor	11.7	17.4	23.2
Vocational rehabilitation specialist	8.3	18.9	19.6
Physiatrist	13.3	16.8	17.9
Radiologist	6.7	17.9	10.7
Audiologist	6.7	14.2	17.9
Social worker ^a	8.3	13.7	14.3
Dietician ^a	3.3	8.4	7.1

^a Item included as a distractor.

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Table 3. Percentage of professionals identified per participant group.

Concussion management professionals	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Primary care/family medicine doctor	73.3	88.4	85.7
Athletic trainer	81.7	84.7	80.4
Emergency room doctor	73.3	83.2	91.1
Neurologist	48.3	72.1	73.2
Coach	68.3	68.4	62.5
Psychologist or neuropsychologist	60.0	67.4	69.6
Nurse	48.3	66.3	73.2
Physical therapist	31.7	52.6	51.8
Occupational therapist	23.3	32.1	46.4
Psychiatrist	38.3	28.9	33.9
Teacher	20.0	30.5	32.1
Academic advisor	25.0	31.1	23.2
Speech-language pathologist	18.3	25.8	37.5
Optometrist/ophthalmologist	13.3	27.4	23.2
Recreational therapist ^a	8.3	22.1	26.8
Chiropractor	11.7	17.4	23.2
Vocational rehabilitation specialist	8.3	18.9	19.6
Physiatrist	13.3	16.8	17.9
Radiologist	6.7	17.9	10.7
Audiologist	6.7	14.2	17.9
Social worker ^a	8.3	13.7	14.3
Dietician ^a	3.3	8.4	7.1

^a Item included as a distractor.

We utilized chi-square analyses to determine potential differences between groups on recognition of professionals involved in concussion management. Significant differences were found between groups for the following items: emergency room doctor, χ²(2, N = 306) = 6.44, p = .040; primary care/family medicine doctor, χ²(2, N = 306) = 8.16, p = .017; nurse, χ²(2, N = 306) = 8.90, p = .012; occupational therapist, χ²(2, N = 306) = 7.17, p = .028; physical therapist, χ²(2, N = 306) = 8.35, p = .015; neurologist, χ²(2, N = 306) = 12.74, p = .002; and recreational therapist, χ²(2, N = 306) = 7.16, p = .028. No other significant differences existed between groups, though athletic level and SLP approached significance, χ²(2, N = 306) = 5.59, p = .061.

A series of follow-up 2 × 2 chi-square analyses were performed to determine individual differences. When comparing varsity and recreational athletes, varsity athletes recognized the following professionals related to concussion significantly less than recreational athletes: primary care/family medicine doctor, nurse, physical therapist, and neurologist. When comparing varsity athletes and non-athletes, varsity athletes recognized the following professionals related to concussion significantly less than non-athletes: emergency room doctor, nurse, occupational therapist, physical therapist, neurologist, and SLP. Varsity athletes were also less likely to associate recreational therapy, a distractor item, with concussion compared with recreational athletes and non-athletes. See Tables 4 and 5 for chi-square values and degrees of significance.

Table 4. Chi-square values—Varsity athletes recognized the following professionals significantly less than recreational athletes.

Variable	χ²	* p
Primary care doctor	8.05	.005
Nurse	6.26	.012
Physical therapist	8.04	.005
Neurologist	11.50	.001
^a Recreational therapist	5.67	.017

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

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Table 4. Chi-square values—Varsity athletes recognized the following professionals significantly less than recreational athletes.

Variable	χ²	* p
Primary care doctor	8.05	.005
Nurse	6.26	.012
Physical therapist	8.04	.005
Neurologist	11.50	.001
^a Recreational therapist	5.67	.017

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

Table 5. Chi-square values—Varsity athletes recognized the following professionals significantly less than non-athletes.

Variable	χ²	* p
Emergency room doctor	6.15	.013
Nurse	7.49	.006
Occupational therapist	7.49	.006
Physical therapist	4.83	.028
Neurologist	6.15	.013
Speech-language pathologist	5.33	.021
^a Recreational therapist	6.91	.009

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

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Table 5. Chi-square values—Varsity athletes recognized the following professionals significantly less than non-athletes.

Variable	χ²	* p
Emergency room doctor	6.15	.013
Nurse	7.49	.006
Occupational therapist	7.49	.006
Physical therapist	4.83	.028
Neurologist	6.15	.013
Speech-language pathologist	5.33	.021
^a Recreational therapist	6.91	.009

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

Concussion Education

History of Concussion Education

Descriptive statistics revealed percentages and frequencies among groups for participation in formal concussion education. When comparing groups, 96.43% (n = 54) of varsity athletes, 77.22% (n = 139) of recreational athletes, and 64.15% (n = 34) of non-athletes reported receiving formal concussion education. A chi-square analysis determined that differences between groups were significant, χ²(8, N = 289) = 42.82, p < .001. A series of post hoc chi-square analyses determined individual significant differences between groups. Varsity athletes were more likely to report participation in formal concussion education than recreational athletes, χ²(4, N = 236) = 21.10, p < .001, and non-athletes, χ²(4, N = 109) = 42.02, p < .001. Recreational athletes also reported greater participation in concussion education than non-athletes, χ²(4, N = 233) = 13.13, p = .011. Respondents who indicated that they had been previously educated on concussion were asked to provide a rating on the perceived quality of education they received. A one-way ANOVA revealed a main effect between groups on rating of education quality, F(2, 208) = 5.20, p = .006. Varsity athletes provided the highest quality rating (M = 3.58, SD = 0.78), followed by recreational athletes (M = 3.45, SD = 0.82), and non-athletes provided the lowest quality rating (M = 3.00, SD = 0.71). Tukey's HSD post hoc analyses revealed significant differences between groups, with non-athletes rating their concussion education as being of a lower quality than both varsity athletes (p = .006) and recreational athletes (p = .016).

Preferred Concussion Education

Respondents also ranked different methods of concussion education by individual preferences. Respondents ranked education by a medical professional as the most preferred method and education from parents as the least preferred method. See Table 6 for results. A series of one-way ANOVAs determined a main effect of athletic level preference of parents as an educational method, F(2, 271) = 3.83, p = .023, with no other significant differences. Tukey's HSD post hoc analyses revealed a difference between varsity athletes (M = 5.53, SD = 1.47) and non-athletes (M = 4.59, SD = 1.89) on the use of parents for concussion education, such that varsity athletes rated parents as a lower preference than non-athletes.

Table 6. Descriptive statistics: Ranking of preferred method of concussion education.

Educational method	M	SD
Nurse, doctor, or other medical professional	2.86	1.95
Videos	3.14	1.72
Coaches	3.97	1.87
Handouts/pamphlets	4.01	1.88
Formal presentations	4.04	1.88
Self-education through books or online	4.92	1.96
Parents	5.06	1.71

Note. Ratings on the basis of a 7-point Likert-type scale, with 1 indicating most preferred education method and 7 indicating least preferred education method.

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Table 6. Descriptive statistics: Ranking of preferred method of concussion education.

Educational method	M	SD
Nurse, doctor, or other medical professional	2.86	1.95
Videos	3.14	1.72
Coaches	3.97	1.87
Handouts/pamphlets	4.01	1.88
Formal presentations	4.04	1.88
Self-education through books or online	4.92	1.96
Parents	5.06	1.71

Note. Ratings on the basis of a 7-point Likert-type scale, with 1 indicating most preferred education method and 7 indicating least preferred education method.

Effect of Previous Concussion Education on Behavior

Respondents also reported if they believe that knowledge or education on concussion changes their behaviors during physical activity. Descriptive statistics revealed that 12.98% (N = 37) of respondents indicated that knowledge on concussion frequently impacts behaviors while performing physical activity, 48.77% (N = 139) selected “Yes, occasionally,” 12.63% (N = 36) selected “Unsure,” and 25.26% (N = 72) selected “No, never.”

Discussion

Concussions impact various aspects of social, vocational, and educational well-being in affected populations (Harmon et al., 2013). At the collegiate level, populations at risk can include varsity and recreational athletes and non-athletes. Research on knowledge of concussion and behavior related to concussion in the college-aged population generally focuses on varsity athletes (Baugh et al., 2014; Fedor & Gunstad, 2015; Kroshus et al., 2013), with limited research targeting the greater population of recreational athletes and non-athletes. This study suggests that there is incomplete knowledge of concussion definition, related symptoms, and professionals involved in concussion management among all college students to varying degrees. Additionally, college students have preferences regarding concussion education that, if utilized, may affect change in behavior related to concussion prevention.

Knowledge of Concussion Definition

Knowledge of the definition of concussion among college students may be incomplete, as illustrated by over 30% of respondents' failure to include involvement of the brain and 80% of respondents' failure to include relevant sequelae when providing a definition. Accuracy in indicating concussion as an injury to the brain has been reported as high as 89% in high school athletes using a fill-in-the-blank question format, rather than the free recall format utilized in this study (Register-Mihalik et al., 2013). The use of a free recall format (i.e., allowing respondents to independently answer questions without being provided choices) provides new insights into not only what information respondents can recognize but also how respondents are able to spontaneously answer concussion-related questions.

Though knowledge of the definition of concussion may be incomplete in the collegiate population, there is improvement in knowledge levels when compared with results from previous studies. As an example, Livingston and Ingersoll (2004) found that more than half of collegiate athletes believed that loss of consciousness was necessary to be diagnosed with a concussion, whereas 0% of collegiate varsity athletes and 3% of recreational athletes in this study believed that loss of consciousness was necessary for diagnosis. In the same respect, McKinlay et al. (2011) found uncertainty in the general public regarding the relationship of loss of consciousness and concussion. However, 91% of non-athletes surveyed in the current study recognized that loss of consciousness was not required for the diagnosis of concussion. The improvement in accuracy may be a result of better knowledge in the collegiate population than the general public or from overall heightened awareness of concussion in the 6 years since the publication of the referenced study. Overall improvement in knowledge of concussion definition is important for collegiate students in order to ensure identification of a potential concussive event. Though collegiate students demonstrated limited spontaneous recall of the definition of concussion, respondents' success in differentiating between loss of consciousness and diagnosis of concussion indicates improved concussion definition knowledge.

Knowledge of Concussion Symptoms

Findings of this study suggest that collegiate varsity athletes, recreational athletes, and non-athletes have an incomplete understanding of concussion sequelae. Over 85% of respondents identified classic somatic and cognitive symptoms of concussion, such as headache, dizziness, and difficulty concentrating, though commonly experienced symptoms, such as fatigue, pain, and amnesia, were recognized less frequently. Of note, no symptoms in this study were identified by all respondents, illustrating incomplete knowledge of even the most commonly reported concussion symptoms (Harmon et al., 2013). Respondents did not readily identify emotional symptoms, such as irritability, depression, and anger/aggression in both free recall and forced-choice formats.

A general trend of limited knowledge of emotional changes following injury is consistent with previous research examining collegiate varsity athlete and non-athlete knowledge of concussion symptoms (Fedor & Gunstad, 2015) and research focused on symptom knowledge in high school athletics (Chrisman et al., 2013; Cournoyer & Tripp, 2014). Varsity athletes' limited recall and recognition of emotional symptoms suggests that current concussion educational methods utilized in annual preseason education may be ineffective in establishing knowledge of emotional sequelae. With regard to non-athletes, previous research has suggested limited identification of somatic and neurocognitive symptoms in the general public (Mulhern & McMillan, 2006). The current study revealed improvement in concussion symptom knowledge in non-athletes, with frequent identification of classic somatic and neurocognitive symptoms associated with concussion. Although, similar to collegiate athletes, non-athletes demonstrated incomplete identification of emotional concussion symptoms. While knowledge of somatic and cognitive concussion symptoms is important for collegiate students, additional knowledge of emotional symptoms improves overall understanding of concussion and potential consequences (Cournoyer & Tripp, 2014). Additionally, if individuals following a concussion are unable to associate emotional deficits with head injury and, thus, fail to report emotional symptoms, he or she may go without appropriate management of these symptoms, though this theory requires further investigation.

Effect of Concussion Symptoms on Academics

Symptoms with direct impact on school performance (e.g., difficulty multitasking, difficulty reading, and difficulty learning new information) were recognized by less than 70% of respondents, suggesting that many college students fail to associate problems in the classroom with concussion. Current empirical evidence suggests that there is higher academic dysfunction associated with concussion as compared with injuries to an extremity and calls for “return-to-learn” guidelines to address the burden of neurocognitive deficits in the classroom (Wasserman et al., 2016, p. 1252). The impact of these cognitive deficits is pertinent not only for college students but also for elementary, middle, and high school students. Accommodations for academic work provide students with the means to follow academic demands in a way that does not overtax neurocognitive functioning and result in worsened or prolonged symptoms (McGrath, 2010). Individuals who sustain a concussion should be aware of potential difficulties with academics to better prepare for possible difficulties in the classroom and make use of any appropriate, available accommodations.

Differences Between Athletes and Non-Athletes

When comparing respondent groups on recall and recognition of concussion symptoms, few significant differences existed between groups. Ultimately, varsity athletes were not significantly more successful in identification of concussion symptoms than the other groups, even with required participation in concussion education programs. These results, in conjunction with varsity athletes' self-ratings of concussion symptom knowledge, indicate that varsity athletes may be unaware of gaps in knowledge and, thus, suggest that related professionals should reexamine methods currently utilized in education of varsity athletes.

Knowledge of Support Services

Across all respondent groups, knowledge of support services available after concussion is incomplete, though respondents demonstrated knowledge of key concussion management personnel. The majority of respondents associated primary care doctors with concussion management, closely followed by athletic trainers. These results indicate that college students recognize hallmark professionals related to concussion. Results from the current study provide support for collegiate students' knowledge of the involvement of athletic trainers in injury management, as over 80% of respondents recognized athletic trainers as being related to concussion. Previous evidence suggests that collegiate varsity athletes most frequently seek out athletic trainers for initial assessment of injury (Broglio et al., 2014; McCrea et al., 2003).

Research is still needed focusing on the use and effectiveness of professional or student personnel utilized during nonvarsity level recreational sports for the identification of suspected concussion, especially as this population does not typically have direct and easy access to medical professionals associated with sport injury management (Musille, 2016). Challenges accompanying the life of collegiate nonvarsity athletes and non-athletes may also affect access to support services following injury (Turner & Keller, 2015). For example, at the college level, students may have limited transportation or experience academic requirements that impede ease of access to medical care. Some students may also be less comfortable managing their health care needs previously maintained by parental figures (Dorman & Christmas, 2002). Others may be concerned about the potential financial burden associated with medical care (Cunningham & Bond, 2013; Turner & Keller, 2015).

Concussion Education

Education is an important facet of health care, ideally involving active engagement of patients, encouragement to take ownership over one's own health (Coulter & Ellins, 2007), and improving health literacy or the ability to apply previous health care knowledge to making sensible decisions in everyday life situations (Kickbusch, Maag, & Saan, 2005). With regard to concussion, improved patient engagement and health literacy may lead to increased frequency of symptom reporting and patient tendency to seek out treatment (Register-Mihalik et al., 2013). Current literature examines the effectiveness of various concussion education methods to determine what type of education methodology can impact meaningful change in target populations (Caron, Bloom, Falcão, & Sweet, 2015; Kroshus et al., 2013; Provvidenza et al., 2013). The majority of research on concussion education currently focuses on sport-related injury as concerns athletes and coaches (Caron et al., 2015). Results from the current study suggest that college students, including athletes and non-athletes, have specific preferences regarding delivery of concussion education.

Effect of Concussion Education on Knowledge

In this study, varsity athletes' self-perception of concussion knowledge of definition, symptoms, and related professionals was significantly higher than the other groups. As over 96% of varsity athletes reported receiving formal concussion education, it is possible that respondents in this group feel knowledgeable about concussion because of their education on the topic. Varsity athletes also rated the quality of their education as the highest, compared with the other groups. Though varsity athletes have the greatest exposure to concussion education, actual knowledge levels regarding definition, symptoms, and support services did not significantly differ from those observed in the other groups. Essentially, even with more frequent and perceived higher quality concussion education, varsity athletes did not have better concussion knowledge than recreational athletes or non-athletes. This finding suggests that current formal concussion education models are ineffective—as suggested in other current research (Baugh & Kroshus, 2016; Kroshus et al., 2013). Those respondents who did not receive mandated, formal concussion training (i.e., non-athletes or recreational athletes) likely have knowledge on the topic through personal experience, related academic work, or from self-education through online or printed resources.

Preferred Concussion Education

Overall, regardless of athletic level, respondents indicated a preference for education provided by a medical professional. Handouts/pamphlets and formal presentations ranked fourth and fifth in the current study, respectively, when compared with other educational methods. The only significant difference between athletic levels existed between varsity and non-athletes, with varsity athletes rating education delivered by parents lower than non-athletes. The difference may be a result of non-athletes' reliance on informal educational methods, such as that provided by parents. However, education via parents may be inadequate to develop sufficient knowledge of concussion, as research suggests that parents may have difficulty with identification of symptoms (Coghlin & Howitt, 2009) and knowledge of postconcussion recovery protocols (Shenouda, Hendrickson, Davenport, Barber, & Bell, 2012). Some collegiate athletes, even though they may not be living at home, continue to perceive pressure from a parent to continue to play after a suspected injury. Athletes who experience this parental pressure are less likely to report concussion-related symptoms than their peers (Kroshus et al., 2013). Previous evidence examining collegiate varsity athlete preferences on concussion educational materials and methods suggests a preference for videos with testimonials delivered by former athletes, a method not specifically included in the current study (Kroshus et al., 2013). Kroshus et al. (2013) examined publicly available concussion educational materials, presumably accessible to recreational athletes and non-athletes as well. Although, if these populations are unaware of readily available materials, they are unable to utilize them for educational purposes.

Effect of Previous Concussion Education on Behavior

Implementation of effective and efficient education is vital to ensure safety of all populations at risk for concussion. As approximately 62% of respondents indicated that their knowledge of concussion frequently or occasionally impacts their behavior during physical activity, improved education can continue to change behavior and promote safety from head injury. Research focusing on high school–level athletics suggests that athletes who receive concussion education are more likely to report symptoms to their coach than those who do not receive education (Bramley et al., 2012). Education on concussion must also go beyond just identification of related symptoms, as current empirical research promotes targeting outcomes demonstrating the transfer of knowledge to actual performance, such as improved concussion reporting behaviors (Kroshus et al., 2013). Further research on most effective concussion educational methods to affect meaningful change in at-risk populations is warranted.

Limitations

Online survey data collection methods allow researchers to obtain confidential preliminary data about the perceptions of a population of interest. Historically, and as observed in the current study, an inherent weakness of early survey research is often a lower response rate and a less diverse number of respondents (Granello & Wheaton, 2004). Although the authors made repeated and equal attempts to obtain a diverse group of participants through the use of multiple recruitment methods to all varsity and club athletes, the final respondent pool lacked a high representation from men and individuals of different ethnic backgrounds. However, respondent self-reported ethnicity mirrored each institution's general population characteristics. These demographic factors may limit generalizability from the current study to other populations or more diverse regions of the United States. Even so, gaps in overall knowledge of concussion and related services found in the current preliminary were evident.

The current study also had greater participation from recreational level athletes than varsity athletes or non-athletes—though this may be reflective of the collegiate population in general. Recreational sports continue to expand on college campuses, with a greater opportunity to be involved in recreational athletics compared with varsity athletics. Thus, the high number of respondents involved in recreational athletics in the current study is likely an accurate depiction of the population of interest.

Another inherent limitation is that the sample collegiate population is generally well-educated. Because of this, the application of our findings to non-college-educated individuals cannot be made. Examination of concussion knowledge among individuals without postsecondary education may also reveal a unique response pattern. An additional limitation is that women demonstrated higher survey participation than men (206 women vs. 99 men). This may be related to increased interest levels on concussion in women, as research shows that women utilize health services more frequently than men (Bertakis, 2009). Gender differences about the utilization of medical services may also influence if an individual seeks out care following a concussion. A recent systematic review revealed that the most prominent barriers to men seeking medical help were a reluctance to express emotions or concerns about health, embarrassment, fear, and poor communication with health care professionals (Yousaf, Grunfeld, & Hunter, 2015). This may be especially prevalent with male students following suspected concussion and may influence response patterns.

Future Directions

Future research examining differences in concussion knowledge between genders, socioeconomic, educational, and ethnic backgrounds is warranted and may lead to even greater discrepancies between these groups. Previous research studies have specifically revealed inconsistent differences in concussion recovery patterns and symptom reporting between male and female athletes (Berz, Divine, Foss, Heyl, Ford, & Myer, 2013; Brown, Elsass, Miller, Reed, & Reneker, 2015; Covassin, Elbin, Bleecker, Lipchik, & Kontos, 2013; Sandel, Schatz, Goldberg, & Lazar, 2017). In one study, female athletes performed significantly worse on neurocognitive measures and reported greater postinjury symptoms when compared with male athletes. A closer examination of the perceived knowledge between these groups may reveal the need to provide gender specific preconcussion and postconcussion educational programs. Because a survey methodology was utilized in the current study, we were unable to probe respondents regarding the rationale for their responses. Future research using other methods of data collection, such as interviews, may reveal unique patterns of response between demographic groups that the researchers did not consider. For example, studies, specifically utilizing interview techniques with collegiate athletes and non-athletes, may also reveal distinctive student perceptions about the strengths/limitations and accessibility of postinjury care.

Management of concussion is highly relevant to the field of speech-language pathology, though knowledge of the potential role of the SLP in concussion appears to be low. SLPs have the knowledge and training in brain injury that make them qualified professionals for management and education of concussion. Furthermore, in sports-related injuries, SLPs are an objective member of the management team with no direct ties to athletics, allowing for the presence of unbiased opinions concerning symptom assessment and management procedures (Knollman-Porter et al., 2014). In addition, SLPs can provide greater knowledge and support for students struggling to perform academically following concussion. Future studies examining the utilization and effectiveness of preconcussion and postconcussion education and management protocols that involve SLPs are warranted.

Conclusion

Knowledge of concussion definition, symptoms, and support services following injury is incomplete in collegiate athletes and non-athletes. Symptoms associated with concussion may negatively impact academic performance for collegiate students. Respondents in this study demonstrated knowledge of basic somatic and neurocognitive concussion-related symptoms but incomplete knowledge of emotional symptoms. In order to seek out treatment following injury, collegiate athletes and non-athletes must first be able to recognize related symptoms associated with concussion. Though college students are largely unaware of the role of the SLP in concussion management, respondents in the current study successfully identified primary members of the management team, including physicians and athletic trainers. Additionally, college students reported preferences in a concussion education that may promote safe behavior during physical activity and reduce the risk of possible head injury. Further research is warranted on the effect of various concussion educational methods, such as those provided by a medical professional, on behavioral outcomes related to concussion. Special focus on the outcomes of educational models implemented for student athletes and non-athletes of differing genders, cultures, socioeconomic, and educational backgrounds should also be examined. With enhanced student knowledge about the sequelae of concussion it is the hope that postinjury management protocols and support services can be implemented sooner in order to promote student success even following injury.

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Appendix

Sample Questions From Concussion Knowledge and History Survey

Concussion Knowledge and History Survey

How would you rate your current knowledge on the following topics?

Definition of a concussion/head injury
Signs and symptoms of concussions/head injuries
Risk factors associated with premature return to play
Typical recovery patterns from concussions/head injuries
Support services available for individuals with concussions/head injuries
“I prefer not to answer this question”

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In your own words, define a concussion/mild head injury.

_____________________________________________

Provide as many symptoms as you can think of that could result from a concussion/mild head injury.

_____________________________________________

Provide a list of professionals who may be involved in the care and recovery of individuals with concussions or mild head injuries.

_____________________________________________

In what level of athletics do you currently participate on a regular basis?

Varsity sports
Club sports
Intramural sports
Recreational sports
None

What sports do you currently play/participate in? (Select all that apply.)

Football
Basketball
Soccer
Hockey
Tennis
Volleyball
Gymnastics
Rugby
Wrestling
Golf
Baseball/softball
Track and field/cross country
Swimming and diving
Rowing
Other: ___________________________

Please answer the following questions relating to concussion/mild head injury. If you are unsure of the answer, you may indicate “Unsure/I don't know.”

Females often experience a longer recovery period following a mild head injury or concussion than males.

TRUE
FALSE
Unsure/I don't know
I prefer not to answer this question

The most commonly experienced symptom following a concussion or mild head injury is which of the following:

Confusion
Headache
Memory problems
Nausea
Unsure/I don't know
I prefer not to answer this question

Symptoms following concussion can negatively impact academic and work performance.

TRUE
FALSE
Unsure/I don't know
I prefer not to answer this question

In order to be diagnosed with a concussion or mild head injury a person must have lost consciousness (i.e., blacked out).

TRUE
FALSE
Unsure/I don't know
I prefer not to answer this question

Select all of the symptoms you would expect a person with a concussion or mild head injury to experience:

Decreased memory for events immediately before the injury
Decreased memory for events immediately after the injury
Planning/organization problems
Slow thinking
Difficulty learning new information
Confusion to your situation
Problems paying attention at school or work
Concentration problems
Difficulty multitasking
Problems starting or finishing tasks
Problems thinking clearly
Difficulty solving problems
Difficulty speaking
Difficulty reading
Difficulty writing
Trouble sleeping
Sleeping more than usual
Dizziness
Headaches
Sensitivity to light or sound
Blindness
Problems focusing your eyes
Deafness
Balance/coordination problems
Reduced mobility
Decreased endurance
Excessive fatigue
Unusual hunger
Loss of appetite
Pain
Depression
Irritability
Mood swings
Anger or aggression
Difficulty with relationships
Decreased self-awareness
Loss of interest in previously enjoyed activities
Panic attacks
None of the above

Select all of the service providers/medical professionals that you would expect to be involved in the treatment and recovery of a person with a concussion or mild head injury:

Emergency room doctor
Primary care/family medicine doctor
Psychologist or neuropsychologist
Psychiatrist
Nurse
Athletic trainer
Teacher
Occupational therapist
Speech-language pathologist
Audiologist
Physical therapist
Chiropractor
Social worker
Optometrist/ophthalmologist
Coach
Academic advisor
Vocational rehabilitation specialist
Recreational therapist
Dietician
Radiologist
Neurologist

The following questions ask about your educational background and thoughts regarding concussion and mild head injury.

Have your previously been educated on mild head injury/concussion?

Definitely yes
Probably yes
Probably not
Definitely not
I prefer not to answer this question

If you have previously been educated, what methods were used to educate you on concussion or mild head injury?

Handouts/pamphlets
Videos
Formal presentations
Self-education through books or online
Parents
Coaches
Nurses, doctors, or other medical professionals
Other: __________
I prefer not to answer this question
Graphic Jump Location

Drag and drop the numbers to rank your preference for educational method when learning about concussion or mild head injury. 1 = most preferred method; 7 = least preferred method.

______ Handouts/pamphlets (1)

______ Videos (2)

______ Formal presentations (3)

______ Self-education through books or online (4)

______ Parents (5)

______ Coaches (6)

______ Nurses, doctors, or other medical professionals (7)

Does your knowledge/education about concussion and mild head injury change your daily behaviors or decisions?

Yes, frequently
Yes, on occasion
Unsure
No, never
I prefer not to answer this question

Does your knowledge/education on concussion and mild head injury change your behaviors or decisions while performing physical activity?

Yes, frequently
Yes, on occasion
Unsure
No, never
I prefer not to answer this question

Have you ever NOT reported concussion-like symptoms to a parent, coach, teammate, etc?

Definitely yes (i.e., you have failed to report symptoms to someone)
Probably yes
Maybe/unsure
Probably not
Definitely not (i.e., you have always reported symptoms to someone)
I prefer not to answer

Table 1. Summary of survey sections and sample question topics.

Topics	No. of questions	Question types	Sample questions
Demographic information	15	• Multiple choice	• Age
Demographic information	15	• Free recall	• Level of athletic participation
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of signs/symptoms associated with concussion
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of the definition of concussion
Concussion definition knowledge	3	• Free recall	• Recall of concussion definition in respondents' own words
Concussion definition knowledge	3	• Multiple choice	• Definition of concussion provided multiple choice options
Concussion symptom knowledge	2	• Free recall	• Recall of concussion symptoms in respondents' own words
Concussion symptom knowledge	2	• Multiple choice	• Selection of relevant symptoms from provided list
Related professionals knowledge	2	• Free recall	• Recall of concussion-related professionals in respondents' own words
Related professionals knowledge	2	• Multiple choice	• Selection of related professionals from provided list
Concussion education experiences	6	• Multiple choice	• Previous methods of concussion education
		• Ranking	• Ranking of concussion educational methods
		• Likert-type

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Table 1. Summary of survey sections and sample question topics.

Topics	No. of questions	Question types	Sample questions
Demographic information	15	• Multiple choice	• Age
Demographic information	15	• Free recall	• Level of athletic participation
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of signs/symptoms associated with concussion
Self-perception of concussion knowledge	6	• Likert type	• Self-rating of knowledge of the definition of concussion
Concussion definition knowledge	3	• Free recall	• Recall of concussion definition in respondents' own words
Concussion definition knowledge	3	• Multiple choice	• Definition of concussion provided multiple choice options
Concussion symptom knowledge	2	• Free recall	• Recall of concussion symptoms in respondents' own words
Concussion symptom knowledge	2	• Multiple choice	• Selection of relevant symptoms from provided list
Related professionals knowledge	2	• Free recall	• Recall of concussion-related professionals in respondents' own words
Related professionals knowledge	2	• Multiple choice	• Selection of related professionals from provided list
Concussion education experiences	6	• Multiple choice	• Previous methods of concussion education
		• Ranking	• Ranking of concussion educational methods
		• Likert-type

Table 2. Percentages of the 20 most frequently identified symptoms per participant group.

Concussion symptoms	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Headache	83.3	91.1	94.6
Concentration problems	83.3	89.5	85.7
Dizziness	78.3	85.8	92.9
Problem focusing eyes	75.0	86.8	91.1
Balance/coordination problems	83.3	86.3	82.1
Slow thinking	76.7	84.7	83.9
Light/sound sensitivity	80.0	81.6	89.3
Confusion to your situation	75.0	82.6	82.1
Problems paying attention at school or work	70.0	78.9	82.1
Pain	73.3	72.6	82.1
Anterograde amnesia	63.3	72.6	87.5
Retrograde amnesia	70.0	75.3	64.3
Difficulty multitasking	63.3	70.0	75.0
Difficulty solving problems	65.0	70.0	69.6
Difficulty reading	61.7	68.4	75.0
Excessive fatigue	66.7	68.9	67.9
Planning/organization problems	61.7	70.5	62.5
Difficulty learning new information	55.0	67.4	60.7
Irritability	61.7	60.0	73.2
Sleeping more than usual	53.3	59.5	66.1

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Table 2. Percentages of the 20 most frequently identified symptoms per participant group.

Concussion symptoms	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Headache	83.3	91.1	94.6
Concentration problems	83.3	89.5	85.7
Dizziness	78.3	85.8	92.9
Problem focusing eyes	75.0	86.8	91.1
Balance/coordination problems	83.3	86.3	82.1
Slow thinking	76.7	84.7	83.9
Light/sound sensitivity	80.0	81.6	89.3
Confusion to your situation	75.0	82.6	82.1
Problems paying attention at school or work	70.0	78.9	82.1
Pain	73.3	72.6	82.1
Anterograde amnesia	63.3	72.6	87.5
Retrograde amnesia	70.0	75.3	64.3
Difficulty multitasking	63.3	70.0	75.0
Difficulty solving problems	65.0	70.0	69.6
Difficulty reading	61.7	68.4	75.0
Excessive fatigue	66.7	68.9	67.9
Planning/organization problems	61.7	70.5	62.5
Difficulty learning new information	55.0	67.4	60.7
Irritability	61.7	60.0	73.2
Sleeping more than usual	53.3	59.5	66.1

Table 3. Percentage of professionals identified per participant group.

Concussion management professionals	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Primary care/family medicine doctor	73.3	88.4	85.7
Athletic trainer	81.7	84.7	80.4
Emergency room doctor	73.3	83.2	91.1
Neurologist	48.3	72.1	73.2
Coach	68.3	68.4	62.5
Psychologist or neuropsychologist	60.0	67.4	69.6
Nurse	48.3	66.3	73.2
Physical therapist	31.7	52.6	51.8
Occupational therapist	23.3	32.1	46.4
Psychiatrist	38.3	28.9	33.9
Teacher	20.0	30.5	32.1
Academic advisor	25.0	31.1	23.2
Speech-language pathologist	18.3	25.8	37.5
Optometrist/ophthalmologist	13.3	27.4	23.2
Recreational therapist ^a	8.3	22.1	26.8
Chiropractor	11.7	17.4	23.2
Vocational rehabilitation specialist	8.3	18.9	19.6
Physiatrist	13.3	16.8	17.9
Radiologist	6.7	17.9	10.7
Audiologist	6.7	14.2	17.9
Social worker ^a	8.3	13.7	14.3
Dietician ^a	3.3	8.4	7.1

^a Item included as a distractor.

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Table 3. Percentage of professionals identified per participant group.

Concussion management professionals	Percent of varsity athletes	Percent of recreational athletes	Percent of non-athletes
Primary care/family medicine doctor	73.3	88.4	85.7
Athletic trainer	81.7	84.7	80.4
Emergency room doctor	73.3	83.2	91.1
Neurologist	48.3	72.1	73.2
Coach	68.3	68.4	62.5
Psychologist or neuropsychologist	60.0	67.4	69.6
Nurse	48.3	66.3	73.2
Physical therapist	31.7	52.6	51.8
Occupational therapist	23.3	32.1	46.4
Psychiatrist	38.3	28.9	33.9
Teacher	20.0	30.5	32.1
Academic advisor	25.0	31.1	23.2
Speech-language pathologist	18.3	25.8	37.5
Optometrist/ophthalmologist	13.3	27.4	23.2
Recreational therapist ^a	8.3	22.1	26.8
Chiropractor	11.7	17.4	23.2
Vocational rehabilitation specialist	8.3	18.9	19.6
Physiatrist	13.3	16.8	17.9
Radiologist	6.7	17.9	10.7
Audiologist	6.7	14.2	17.9
Social worker ^a	8.3	13.7	14.3
Dietician ^a	3.3	8.4	7.1

^a Item included as a distractor.

Table 4. Chi-square values—Varsity athletes recognized the following professionals significantly less than recreational athletes.

Variable	χ²	* p
Primary care doctor	8.05	.005
Nurse	6.26	.012
Physical therapist	8.04	.005
Neurologist	11.50	.001
^a Recreational therapist	5.67	.017

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

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Table 4. Chi-square values—Varsity athletes recognized the following professionals significantly less than recreational athletes.

Variable	χ²	* p
Primary care doctor	8.05	.005
Nurse	6.26	.012
Physical therapist	8.04	.005
Neurologist	11.50	.001
^a Recreational therapist	5.67	.017

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

Table 5. Chi-square values—Varsity athletes recognized the following professionals significantly less than non-athletes.

Variable	χ²	* p
Emergency room doctor	6.15	.013
Nurse	7.49	.006
Occupational therapist	7.49	.006
Physical therapist	4.83	.028
Neurologist	6.15	.013
Speech-language pathologist	5.33	.021
^a Recreational therapist	6.91	.009

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

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Table 5. Chi-square values—Varsity athletes recognized the following professionals significantly less than non-athletes.

Variable	χ²	* p
Emergency room doctor	6.15	.013
Nurse	7.49	.006
Occupational therapist	7.49	.006
Physical therapist	4.83	.028
Neurologist	6.15	.013
Speech-language pathologist	5.33	.021
^a Recreational therapist	6.91	.009

Note. All tests have 1 degree of freedom. ^a Distractor item. * p < .05.

Table 6. Descriptive statistics: Ranking of preferred method of concussion education.

Educational method	M	SD
Nurse, doctor, or other medical professional	2.86	1.95
Videos	3.14	1.72
Coaches	3.97	1.87
Handouts/pamphlets	4.01	1.88
Formal presentations	4.04	1.88
Self-education through books or online	4.92	1.96
Parents	5.06	1.71

Note. Ratings on the basis of a 7-point Likert-type scale, with 1 indicating most preferred education method and 7 indicating least preferred education method.

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Table 6. Descriptive statistics: Ranking of preferred method of concussion education.

Educational method	M	SD
Nurse, doctor, or other medical professional	2.86	1.95
Videos	3.14	1.72
Coaches	3.97	1.87
Handouts/pamphlets	4.01	1.88
Formal presentations	4.04	1.88
Self-education through books or online	4.92	1.96
Parents	5.06	1.71

Note. Ratings on the basis of a 7-point Likert-type scale, with 1 indicating most preferred education method and 7 indicating least preferred education method.

Definition of a concussion/head injury
Signs and symptoms of concussions/head injuries
Risk factors associated with premature return to play
Typical recovery patterns from concussions/head injuries
Support services available for individuals with concussions/head injuries
“I prefer not to answer this question”

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