CJSM Journal Club — Nondisclosure of concussion symptoms by athletes

Jason Zaremski MD, au courant with medical clothing styles circa 2020. Go Gators!

Our May 2020 issue has recently published, and as ever our Jr. Assoc. Editor Dr. Jason Zaremski is ready to share his pick for the newest CJSM Blog Journal Club.

Concussion Symptom Underreporting Among Incoming National Collegiate Athletic Association Division I College Athletes is the subject for today’s blog post.

Dr. Zaremski is himself a physician at The University of Florida, well known for its Division 1 College Athletic program, the Florida Gators. Whether we treat collegiate athletes, pros, or children, we in sports medicine ALL have an interest in addressing the issue of concussion nondisclosure.

Thanks to the authors for this timely study, and thanks to Dr. Zaremski for your ongoing contributions in this journal club.


Jason Zaremski, MD

Introduction:  As we enter the early stages of the summer and approach a “new normal” with regards to sports, it is incumbent upon sports medicine team physicians to be vigilant as we bring freshman athletes to college campuses with potentially different methods to screen and perform pre-participation physical examinations. While dealing with the new challenges COVID will pose, including the possibility of conducting assessments remotely, clinicians will need, as always, to obtain accurate historical information in order to care for our student-athletes. With that in mind, we present the May 2020 Journal Club on Concussion Symptom Underreporting Among Incoming National Collegiate Athletic Association Division I College Athletes by Dr Fiona Conway and colleagues.

Purpose: To examine concussion knowledge and the relationship of knowledge to reasons for concussion symptom nondisclosure in NCAA Division one incoming athletes.

Methods/Design:  Cross-sectional survey study

Participants: 156 incoming NCAA Division I student-athletes (age 18.4 ±1.0 years; 49% female; 66% white, 128 incoming first year and 28 transfer student-athletes) from 20 NCAA Division I teams. The Institutional Review Board for the Protection of Human Subjects at the university approved the study.

Data Acquisition:  Data were collected during pre-participation athletic evaluations via electronic survey. The survey was a 63-item survey about general health, sport and brain health history, concussion knowledge, attitudes, and beliefs. This survey was developed by physicians and researchers based on literature reviews, focus groups, field experts, and existing protocols in the concussion field. The 30-minute survey included items related to concussion knowledge, attitudes, and beliefs.

The 4 sections of the survey instrument included:

  • Previous Concussion Experience
  • Concussion Knowledge
  • Concussion Symptom Hiding: Attitudes and Beliefs
  • Athletic Stakeholders: Attitudes and Beliefs

Outcome Measures:

  • Previous concussion diagnosis
  • Concussion fact and symptom knowledge
  • Reasons and situational contexts for nondisclosure
  • Stakeholder attitudes


Athletes defined “high” stakes as:

Beginning of the season, competition and competition at the beginning, winning, and being a star player

Athletic stakeholders included:

Teammates, Strength Trainers, Athletic Trainers, Assistant Coaches, and Head Coaches.

Statistical Measures/Analysis:  As stated by the authors, all analyses were performed in SAS 9.4 (SAS Institute, Cary, NC). The demographic characteristics of the sample, previous concussion experience, and knowledge and symptom reporting scores were assessed with univariate analyses.  χ2 tests assessed prevalence of concussions by sport risk category and sex, and t tests assessed concussion knowledge and symptom reporting scores by sport risk category, sex, previous concussion diagnosis, and certainty of previous concussion experience.

Correlations were performed between knowledge and symptom hiding. Results were considered significant at P< 0.05. A post hoc power analysis revealed that the sample size was sufficient to detect a medium effect with the χ2 (w = 0.25, >80%), t tests (d = 0.50, >80%), and bivariate correlations (0.25, >80%).

Furthermore, in order to determine whether the inclusion of transfer students unduly influenced the results, analyses were performed on the subset of incoming first year students with no previous college experience (n = 128).

Results/Outcomes: As noted in the manuscript, concussion risk was calculated by separating sports teams into high-risk [1) high school rate of at least 1/10,000 athletic exposure (AE), and (2) a college rate of at least 3/10,000 AE] and low-risk teams. Of those participants that sustained ≥1 concussion, the most common sports included women’s basketball, women’s soccer, men’s wrestling, men’s soccer, women’s field hockey, and men’s lacrosse. When comparing those athletes that participated in low risk sports, athletes that participated in high-risk sports reported a significantly higher percentage of concussion diagnoses (73%, p=0.0071).

A total of 30 athletes (19%) had been diagnosed with a concussion previously whereas 89 athletes (57%) were certain they had sustained a concussion previously. In other words, 59 athletes thought they might have sustained a concussion but were not diagnosed with one (though as to why is unknown). 59% of all athletes confirmed 9 or more out of 13 reasons for hiding concussion symptoms.

Most common reasons athletes answered for hiding concussion symptoms (% reporting):

  • They think they CAN just “tough it out.” (91.7)
  • They do not want to be pulled out of the game or practice. (90.4)
  • They are afraid they will lose future playing time. (86.5)
  • They do not want to let down their teammates and coaches. (84.6)
  • They do not think it is serious enough. (84.0)
  • They do not know they have a concussion. (83.3)
  • They do not want to appear weak. (80.8)
  • They think they SHOULD just “tough it out.” (79.5)
  • They are afraid they will lose their spot on the team. (75.6)
  • They are afraid the coach will be mad. (64.1)
  • They are afraid their teammates will be mad. (58.3)
  • They think getting concussions is just part of the game. (44.2)
  • They do not believe that their coaches want them to report it. (30.1)

Summarizing all of the data from the survey revealed:

  • Participants had extensive knowledge regarding concussion symptoms and facts
  • Participants with greater concussion fact knowledge endorsed more reasons that athletes may hide symptoms.
  • Concussion symptom knowledge was unrelated to reasons for nondisclosure.
  • Athletes believed that symptom reporting was less likely to occur in high-stakes versus low-stakes situations
  • Athletes identified teammates as holding attitudes that support underreporting
  • Athletes identified athletic trainers as engaging in behaviors that support player safety


  • Unique approach to obtaining objective data with typically subjective responses
  • Incorporates a wide range of data (such concussion experience and knowledge, attitudes, beliefs, different stakeholders)
  • Provides growing evidence of the importance of communication that incorporates the entire team (from athlete to coaching staff to sports performance to sports medicine caregivers)

Weaknesses: As stated by the authors,

  • Results are based on responses to a survey developed specifically for this study.
  • There is no validation of the survey instrument
  • It is challenging to extrapolate one year’s worth of data and only 156 total incoming NCAA athletes to all athletes at all levels of competition
  • Concerning that team physicians not part of the athletic stakeholders


Greater concussion knowledge did not reduce the number of reasons that participants viewed as reasons for concussion nondisclosure. Essentially, authors concluded that participants understood why athletes choose to hide symptoms even when they also understood the symptoms, risks, sequelae, and consequences of concussions. This opinion also seemed to influence symptom disclosure decisions.

Some recommendations include a multifaceted approach to concussion education as well as an improvement in cultural attitudes and beliefs of concussion symptom nondisclosure.

Clinical Relevance:

Even though many incoming NCAA athletes have substantial knowledge regarding concussions, it is still concerning that, as revealed in table 3, perceived attitudes and beliefs from athletes and potential stakeholders affect an athlete’s willingness to divulge concussion related symptoms. Furthermore, incorporating similar questions but including sports medicine team members beyond athletic trainers (eg the team physicians) may change data and results.


Thank you Dr. Zaremski.

Concussion education is not sufficient as primary or secondary injury prevention, as the authors themselves state in their conclusions.  We need a culture change:

“A multifaceted approach that goes beyond current educational strategies to addresses situational, social, and athletic pressures may be needed to initiate a widespread cultural shift away from concussion nondisclosure.”

About sportingjim
I work at Nationwide Children's Hospital in Columbus, Ohio USA, where I am a specialist in pediatric sports medicine. My academic appointment as an Associate Professor of Pediatrics is through Ohio State University. I am a public health advocate for kids' health and safety. I am also the Deputy Editor for the Clinical Journal of Sport Medicine.

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