STOP ‘Playing Through It’

Understand the consequences of delayed concussion reporting and help end the current mentality in sports.

Over the past couple of decades, there has been a reported increase in diagnosed concussions (1-2). Despite this, it is estimated that up to 50% of concussions go unreported by athletes. 

Athletes may not report their symptoms – or may delay the reporting of their symptoms – for a wide variety of reasons: from not wanting to disappoint their teammates, to not believing their symptoms are “serious enough to warrant medical attention,” to potentially even being unaware that they have a concussion (3).

Given the knowledge of what happens in the brain when concussed and the brain’s window of vulnerability (i.e., the brain’s susceptibility to “amplified and exponential damage if repeated injuries are sustained shortly after the initial concussion”) that has been described in concussion research literature, it is reasonable to speculate that delaying the reporting of concussion and continuing to compete in the practice or game may exacerbate processes that are happening in the brain and be detrimental to recovery.

A study published in 2016 decided to explore if there are any impacts on athletes who delay their reporting of their concussion and, consequently, their removal from athletic activity. The study compared the recovery time of athletes who were immediately removed from an activity after a sustained concussion versus those who delayed reporting and were not immediately removed from activity.

The research team obtained data from the University of Florida Concussion Database. This database contains “concussion-related medical history, injury event details, and assessment data on student-athletes participating in the university’s varsity athletic programs.” 

Ninety-seven athletes that sustained concussions between 2008-2015 were identified and analyzed. These athletes sustained concussions from various sports, including men’s football, basketball, swimming, and diving alongside women’s lacrosse, soccer, basketball, volleyball, track and field, gymnastics, swimming, and diving.

What are the Consequences of Delaying Reporting?

There were six main findings of this study:

1. Athletes in the delayed reporting group averaged almost five more days missed from sporting activities compared to the athletes who immediately reported their concussion, which is likely to have substantial consequences for athletic and academic participation.
2. Athletes in the delayed reporting group were around two times more likely to have prolonged recovery* compared to those who immediately reported their concussion 
3. Athletes with a previously diagnosed psychological condition were one time more likely to have a prolonged recovery than those with no previously diagnosed psychological condition.
4. No associations were found between immediate or delayed reporting and sex, history of concussion, or game vs. practice event.
5. Similarly, no associations were found between prolonged versus normal recovery and a learning disability diagnosis, ADHD diagnosis, or concussion history.
6. The average days missed did not differ before and after the implementation of the graduated return-to-play protocol in the 2009 Consensus Statement on Concussion in Sport nor after the release of the 2010 National Collegiate Athletic Association mandate on concussion management, which questions the value and impact of documents such as these.

*Normal recovery was defined as seven or fewer days, and prolonged recovery was defined as eight or more days.

Other Factors Impacting Prolonged Recovery

Interestingly, the first finding above occurred even after controlling for other potential variables for prolonged recovery, including sex, concussion history, learning disability diagnosis, ADHD diagnosis, diagnosed psychological disorders, and acute symptom severity. 

This means that none of these variables were predictors of days missed from sport. This is contrary to previous research that has described these factors as contributing to prolonged recovery (4-13). 

The researchers of this study suggest that their finding does not negate these studies’ findings but that it is important to research further the relationship between these other factors and timing of removal from activity in regards to prolonged recovery.

The Importance of these Findings

While this study was not perfect – for instance, male athletes and football players were overrepresented, and it was a retrospective study that relied on medical records that, in some cases, were incomplete – this study is the first to provide evidence that remaining in play after a concussion carries significant consequences in terms of prolonging recovery time. 

These findings are consistent with other research that describes the brain’s window of vulnerability after a concussion and thereby seems to suggest that athletes who continue to play in sport once concussed are exposing their already injured brain to stress further whether by physical exertion, repeated brain impacts, or both (14-16). 

These findings build upon preclinical studies that found that exercising too soon after concussion can lead to detrimental outcomes (17-19).

More importantly, these findings support the claim that it is important to immediately report signs and symptoms of concussion rather than play through the injury. 

Given the low percentage of athletes that do not immediately report symptoms of concussion and the apparent need to educate athletes about prompt reporting, hopefully, these findings – if taught to athletes – will provide the athletes with the incentive to disclose suspected concussion immediately and protect them from unnecessary risks.

Indeed, it should be emphasized by the persons educating athletes about concussion that immediate reporting and removal from play is the best practice for the health and safety of the athlete, but also is in the best interests of teammates and coaches because the athlete will miss the shortest amount of time possible. This means that athletes should receive education on the “symptoms worthy of immediate reporting” so that they can be evaluated promptly. Ultimately, there is a need for systematic concussion education to ensure athletes, coaches, teammates, and all support staff know the importance of immediate symptom reporting for concussion injuries to stop the ‘playing through it’ culture that is so prominent in sport.

Bibliography

1. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–319.
2. Kilcoyne KG, Dicken JF, Svoboda SJ, et al. Reported concussion rates for three division I football programs: an evaluation of the new NCAA concussion policy. Sports Health. 2014;6(5):402–405.
3. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13–17
4. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich, November 2012. J Athl Train. 2013;48(4):554–575.
5. Waljas M, Iverson GL, Lange RT, et al. A prospective biopsychosocial study of the persistent post-concussion symptoms following mild traumatic brain injury. J Neurotrauma. 2015;32(8):534–547.
6. Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma. 2015;32(8):517–526.
7. Meares S, Shores EA, Taylor AJ, et al. The prospective course of postconcussion syndrome: the role of mild traumatic brain injury. Neuropsychology. 2011;25(4):454–465.
8. Guskiewicz KM, Weaver NL, Padua DA, Garrett WE. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643–650.
9. Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA. 2003;290(19):2549–2555.
10. Eisenberg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics. 2013; 132(1):8–17.
11. Meehan WP, Mannix RC, Stracciolini A, Elbin RJ, Collins MW. Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. J Pediatr. 2013;163(3):721– 725.
12. Meehan WP, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology. 2014;83(24):2204–2210.
13. McCrea M, Guskiewicz K, Randolph C, et al. Incidence, clinical course, and predictors of prolonged recovery time following sportrelated concussion in high school and college athletes. J Int Neuropsychol Soc. 2013;19(1):22–33.
14. Tavazzi B, Vagnozzi R, Signoretti S, et al. Temporal window of metabolic brain vulnerability to concussions: oxidative and nitrosative stresses—part II. Neurosurgery. 2007;61(2):390–395.
15. Vagnozzi R, Tavazzi B, Signoretti S, et al. Temporal window of metabolic brain vulnerability to concussions: mitochondrial-related impairment—part I. Neurosurgery. 2007;61(2):379–389.
16. Vagnozzi R, Signoretti S, Tavazzi B, et al. Temporal window of metabolic brain vulnerability to concussion: a pilot 1H-magnetic resonance spectroscopic study in concussed athletes—part III. Neurosurgery. 2008;62(6):1286–1296
17. Griesbach GS. Exercise after traumatic brain injury: is it a doubleedged sword? PM R. 2011;3(6 suppl 1):S64–S72.
18. Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience. 2004;125(1):129–139.
19. Griesbach GS, Gomez-Pinilla F, Hovda DA. The upregulation of plasticity-related proteins following TBI is disrupted with acute voluntary exercise. Brain Res. 2004;1016(2):154–162.