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Concussion Symptoms and Return to Play: Student-Athlete Subjectivity

By NCAA Sport Science Institute

We begin another wonderful fall with students returning to the classroom and student-athletes engaging in both academics and competitive fall sports. With regard to contact sports, we continue to understand more about concussion and the treatment of concussion brought on by a convergence of scientific inquiry, clinician input and three recent guideline papers (Zurich, American Medical Society for Sports Medicine, American Academy of Neurology). For the first time, there is universal consensus that athletes who are diagnosed with concussion must not return to play or practice that day, and must receive clearance from a clinician with concussion experience before returning to play. While this consensus seemingly provides a concrete plan when an athlete suffers a concussion, there are no objective biomarkers to diagnose concussion. Thus, concussion remains a clinical diagnosis based on subjective symptoms coupled with physical exam findings and ancillary test results.

Because of the subjective nature of concussion, the clinician must combine his or her clinical skills with a working relationship with the student-athlete that centers on trust and transparency. The student-athlete needs to trust the treating clinician, and needs to know that all medical decisions are based on what is best for the safety, health and excellence of the student-athlete. There must be no conflict of interest in medical decision making. Within this conceptual framework, the clinician must also trust that the student-athlete is being forthright about reporting his or her symptoms, especially because the symptoms of concussion guide diagnosis and treatment more than any available objective biomarkers.

Unfortunately, two recent papers tell us that student-athletes are not always forthright about reporting concussion symptoms, and that education is having little impact on such reporting. In a paper by Torres et al (Neurology Clinical Practice, August 2013), 43 percent of student athletes with a history of concussion reported that they had knowingly hidden symptoms of a concussion to stay in a game; 22 percent indicated that they would be unlikely or very unlikely to report concussion symptoms to a coach or athletic trainer in the future. Male athletes and athletes with a prior history of concussion were more likely to indicate that they would not report future concussion symptoms, despite acknowledging they had received formal education in concussion. Kroshus et al (BJSM August 2013) studied college ice hockey student-athletes, and note that there was divergent concussion education among member institutions, and the education did not significantly improve concussion knowledge or affect the decision to continue playing while experiencing concussion symptoms.

These two papers tell us that concussion education needs to be improved and evaluated so that we can better ensure that we are having an impact on behavior. In essence, there needs to be a cultural shift in which student-athletes, coaches, administrators and clinicians universally embrace the notion that concussion symptoms must be acknowledged by student-athletes so that they can be managed in accordance with existing guidelines. Working with you, the NCAA Sport Science Institute hopes that we will achieve this necessary cultural shift through a more robust and evidence-driven educational paradigm. Just as importantly, the NCAA Sport Science Institute is participating in multiple studies and projects that are advancing the field of concussion biomarkers, which will one day, remove much of the uncertainty surrounding subjective symptom reporting.

It is important to continue to emphasize to student-athletes the importance of recognizing, reporting and properly managing concussions.  Please encourage all student-athletes to watch the NCAA concussion education video: Concussions - Don't Hide It, Report It, Take Time to Recover.



Last Updated: Sep 12, 2013