Concussion:Prevention Through Education

Tamara Valovich McLeod, PhD, ATC, FNATAProfessor and Director, Athletic Training Programs

Research Professor, School of Osteopathic Medicine in ArizonaDirector, Athletic Training Practice-Based Research Network

Objectives

• Discuss the need for concussion education• Discuss the effectiveness of concussion

educational interventions• Describe concussion education within a public

health framework• Describe the need for knowledge translation• Future directions for prevention through

education

The Problem

Lack of Awareness

Unrecognized concussion

Catastrophic injury

Concussion Recognition ProblemsMedical Professionals• Hospital discharge (Genuardi & King, 1995)• MDs, NPs (Bazarian, 2001; Zonfillo, 2012; White 2013; Stoller, 2014, Carl, 2014)• Primary Care (Pleacher & Dexter, 2006; Lebrun, 2013)

Coaches• High school (O’Donoghue, 2009)• Youth (Valovich McLeod, 2007, Mrazik, 2011)

Athletes• College (Kaut, 2003; LaBotz, 2004)• High school (McCrea, 2004; Valovich McLeod, 2006; Sye, 2006; Register-Mihalik, 2013; Cournoyer,

2015; Delahunty, 2015Kurowski, 2014)• Youth (Williamson, 2006; Gourley, 2010)

Parents• Youth (Sullivan, 2009; Gourley, 2010; Stevens 2010; Lin, 2015)

Education• State Laws

– All require some form of education– Varies as to whom and how often

• Interscholastic Association: Parent/Athlete– Majority (n=30) use information handouts– 2 require online training (AZ, OR)– 2 refer to CDC web training (GA, IL)– 3 encourage NFHS training (RI, VA, WI)

• Interscholastic Association: Coach– Most require NFHS training for head coaches

Impact of State Laws

• More recent studies indicate knowledge is improving– Physician (Chrisman, 2011)

– Youth athletes (Bloodgood, 2013; Chrisman, 2014)

– Youth parents (Bloodgood, 2013; Chrisman, 2014)

– Coaches (Chrisman, 2014)

Education for Prevention

• Primary prevention– Protect from concussion for occurring in the first

place– Pre-season

• Secondary prevention– Limiting long term disability and preventing re-

injury– Post-injury education– Appropriate management

Education

Valovich McLeod, Kinesiology Reviews, 2015

Effect of Educational Intervention• Improved immediate

knowledge– Cook, 2003– Goodman, 2006– Glang, 2010– Koh, 2011– Bagley, 2012– Miyashita, 2013– Manasse-Cohick, 2014– Cusimano, 2014– Hunt, 2015

• No effect on knowledge– Echlin, 2010– Kroshus, 2013– Cusimano, 2014– Manasse-Cohick, 2014– Register-Mihalik, 2015 – Register-Mihalik, 2015

Increase in immediate knowledge in some studies but the long-term effects of interventions on retention and reporting behaviors are unclear (Caron, 2015)

Reporting Intention

• Soccer athletes more likely to report to coach following education (Bramley, 2012)

• Increased knowledge not associated with self-reporting (Kurowski, 2014; Kroshus, 2013, 2014)

• Intention to report was associated with in-season reporting (Kroshus, 2014)

• Parental attitudes more predictive of care-seeking behaviors (Register-Mihalik, 2015)

Public Health Framework

Surveillance

Risk Factors

Interventions

Evaluate Outcomes

(Binder, 2005)

Public Health Framework: Concussion Education

Concussion reporting

What makes people

report a concussion?

Develop concussion education programs

Has reporting

increased?

(Binder, 2005)

Theory of Planned Behavior (TPB)• Expectancy value theory• “The most important predictor of behavior is

the intention to perform that behavior”

Intention

Attitudes

Subjective Norms

Perceived Behavioral Control

(Kroshus, 2014; Register-Mihalik, 2013)

Theory of Reasoned Action• Behavior intention• Attitude (direct and indirect)• Subjective norm (direct and indirect)

Theory of Planned Behavior• Perceived behavioral control (direct

and indirect)

(Kroshus, 2014; Register-Mihalik, 2013)

Socio-ecological Framework

• Broad perspective that evaluates multiple levels of influences on health behaviors– To understand behavior need to consider all levels

of the ecological system– Also consider the inter-relations and interactions

among these levels– Examines the cumulative impact of multiple levels

of influence,• Individual behaviors, peer networks, physical and social

environments and relevant policies

Kerr, 2014

Kerr, 2014

Policy

Environment

Interpersonal

Intrapersonal

Knowledge Translation• Key component to the success of any concussion

education• “the exchange, synthesis, and ethically sound

application of knowledge within a complex system of interactions among researchers and users” (Canadian Institute of Health Research: http://www.cihr-irsc.gc.ca/e/29418.html)

• Ensuring that sound educational programs are successful in modifying reporting behavior and ensuring proper post-injury management processes

Knowledge Translation

Define target audience

Determine message to be delivered

Identify the messenger

Decide on mode of delivery

Evaluate impact on outcome(s)

Provvidenza, 2009

Developing Effective Education:Concussion Reporting Barriers

• Athletes know concussions are dangerous• Most would still play with symptoms• Athletes want to keep playing• It’s hard to tell if you are injured• You’re supposed to play injured• Don’t want to let team down• Hesitant to report to coach

Chrisman, 2012

Developing Effective Education: What Do Athletes Want?

• Content– Symptoms– Proper management– Long-term issues– Impact on athletic

performance– Impact on academics– Importance of self-

reporting

• Mode of Delivery– Lecture (57%)– Video (54%)– Handout (28%)

• 40% want education provided by coach

Kroshus, 2015

Future Directions for Education

• Awareness education should be targeted – Appropriate modalities– Culturally relevant tools– Community medical providers– Academic accommodations

• Shift from awareness education to other areas– Behavior modification– Technique training

BAKPAC Studies

• Beliefs, Attitudes, and Knowledge of Pediatric Athletes with Concussion – Athletic Trainers– Primary Care Providers (MD/DO, PA-C)– School Nurses– School Counselors– Principals– Superintendents– Teachers

Medical: Welch, Williams, Weber, Kay, Erickson, Sleight , McLeod , Valovich McLeod School: Welch , Register-Mihalik Kasamatsu, Johnson, Shumaker, Valovich McLeod

Valovich McLeod, Kinesiology Reviews, 2015

• HUF, NHUF, HUF+PW• Practice injury rate: HUF & HUF+PW < NHUF• Game injury rate: HUF+PW < NHUF• Practice concussion rate: HUF+PW < NHUF in 11-15 y/o• Head impacts in practices: HUF < NHUF (Kerr, OJSM, In Press)

OJSM, 2015; 3(7)

Helmetless Tackling Technique

Medical Professional

Education

Medical Professional

Presence

Parent Education

Coach Education

Athlete Education

Culture of Sport

Proper Technique

Athlete Reporting

Coach Identification

Medical Professional Identification

in injuries indentified

Proper Management

Concussive Injuries

Outcomes

Developing a Prevention Model

Appropriate Tools and

Plan

Slide Courtesy of Johna Register-Mihalik, PhD, ATC

Summary

• Public health approach is very useful for concussion

• Need to determine intended outcomes for interventions

• Need to determine most effective manner in which to educate

• Evaluate other potential prevention mechanisms

www.atsuconcussion.comtmcleod@atsu.edu

480-219-6035

www.atpbrn.org

SPORT CONCUSSION SUMMIT

September 24, 2015 #uminjuryctr