FACTORS THAT INFLUENCE COLLEGIATE VARSITY ATHLETES’
KNOWLEDGE OF CONCUSSIONS

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

by
Angela Boyle

Research Advisor, Dr. Jamie Weary
California, Pennsylvania
2012

ii

iii

ACKNOWLEDGEMENTS
I would like to take this opportunity to identify and
thank the individuals who have directly and indirectly
impacted my life and helped in the completion of this
thesis. I would first like to thank my family for the
support throughout this whole process. You all helped me
see the light at the end of the tunnel and to achieve all
of my goals so far.
I would also like to thank my thesis committee - Dr.
Jamie Weary, Dr. Linda Meyer, and Vilija Bishop - for their
hard work and time put into this paper. Your guidance and
feedback helped make this paper into something that I am
very proud to have written. Thanks to the athletes who
participated in my survey, I wouldn’t have had a paper
without you.
Next, I would like to thank my Penn State Fayette
staff and athletes. You all made my first year as a
Certified Athletic Trainer amazing. I am so grateful for
the great welcome I was given and the freedom I enjoyed. I
had a great year and even better experiences.
Lastly, I would like to thank my CalU professors and
classmates. I formed lasting relationships that I know will
last, and am grateful to know all of you.

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS

. . . . . . . . . . . . . . iv

LIST OF TABLES

. . . . . . . . . . . . . . . vii

LIST OF GRAPHS

. . . . . . . . . . . . . . . viii

INTRODUCTION
METHODS

. . . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . . 6

Research Design
Subjects

. . . . . . . . . . . . . . 6

. . . . . . . . . . . . . . . . . 7

Preliminary Research. . . . . . . . . . . . . 7
Instruments . . . . . . . . . . . . . . . . 8
Procedures

. . . . . . . . . . . . . . . . 9

Hypotheses

. . . . . . . . . . . . . . . . 10

Data Analysis
RESULTS

. . . . . . . . . . . . . . . 11

. . . . . . . . . . . . . . . . . . 12

Demographic Information
Hypothesis Testing

. . . . . . . . . . . 12

. . . . . . . . . . . . . 15

DISCUSSION . . . . . . . . . . . . . . . . . 20
Discussion of Results . . . . . . . . . . . . 20
Conclusions . . . . . . . . . . . . . . . . 24
Recommendations. . . . . . . . . . . . . . . 25

v
REFERENCES . . . . . . . . . . . . . . . . . 26
APPENDICES . . . . . . . . . . . . . . . . . 28
APPENDIX A: Review of Literature

. . . . . . . . 29

Introduction . . . . . . . . . . . . . . . . 30
Concussions . . . . . . . . . . . . . . . . 31
Definition . . . . . . . . . . . . . . . 32
Impact on Brain . . . . . . . . . . . . . 33
Mechanisms of Injury

. . . . . . . . . . 34

Incidence Rates . . . . . . . . . . . . . 36
Recognition. . . . . . . . . . . . . . . . . 39
Signs and Symptoms .
Diagnosis

. . . . . . . . . . 39

. . . . . . . . . . . . . . . 42

Management and Neurocognitive Perfo rmance . . 44
Management . . . . . . . . . . . . . . . 45
Neurocognitive Testing

. . . . . . . . . 47

Long Term Effects . . . . . . . . . . . . . 53
Return to Play

. . . . . . . . . . . . . . 57

APPENDIX B: The Problem . . . . . . . . . . . . 61
Statement of the Problem . . . . . . . . . . . 62
Definition of Terms . . . . . . . . . . . . . 63
Basic Assumptions . . . . . . . . . . . . . . 63
Limitations of the Study . . . . . . . . . . . 64
Significance of the Study

. . . . . . . . . . 64

APPENDIX C: Additional Methods .

. . . . . . . . 66

vi
Concussion Knowledge Survey and Answer Key (C1) . . 67
IRB: California University of Pennsylvania (C2) . . 84
Cover Letter (C3) . . . . . . . . . . . . . . 102
REFERENCES . . . . . . . . . . . . . . . . . 105
ABSTRACT . . . . . . . . . . . . . . . . . . 110

vii
LIST OF TABLES
Table

Title

Page

1

Gender Classification . . . . . . . . . . . . 13

2

Participation in Concussion Education

3

Sport Classification . . . . . . . . . . . . 13

4

Years of Varsity Athletic Experience
Classification . . . . . . . . . . . . . . 14

5

History of Concussions

6

Concussion Knowledge Score . . . . . . . . . . 14

7

Independent t-test group statistics:
Hypothesis 1 . . . . . . . . . . . . . . . 15

8

Independent t-test: Hypothesis 1

9

Pearson Correlation: Hypothesis 2 . . . . . . . 16

10

Independent t-test group statistics:
Hypothesis 3 . . . . . . . . . . . . . . . 18

11

Independent t-test: Hypothesis 3

12

Independent t-test group statistics:
Hypothesis 4 . . . . . . . . . . . . . . . 18

13

Independent t-test: Hypothesis 4

Training

. 13

. . . . . . . . . . . 14

. . . . . . . 16

. . . . . . . 18

. . . . . . . 19

viii
LIST OF GRAPHS
Graph
1

Title

Page

Plot Graph Showing Pearson Correlation Between
Years of Experience and Percentage on Concussion
Knowledge Test . . . . . . . . . . . . . . 17

1

INTRODUCTION

It is estimated that there are 3.8 million sportsrelated concussions diagnosed each year.1 Due to the
increasing incidence rate and the latest research,
concussions have become a hot topic in the sports and
medical communities. Most research thus far has focused on
educating allied health and medical professionals such as
athletic trainers and team physicians on how to effectively
recognize, diagnose, and treat concussions with an emphasis
on return to play criteria. However, the many factors that
affect athletes’ knowledge of concussions, most
specifically the causes, signs and symptoms, serious longterm effects, and the return to play criteria, as well as
the role of the athlete throughout the entire process, has
not been identified. The purpose of the study was to
examine factors that affect concussion knowledge in
collegiate varsity athletes. Factors that were examined
include participation in a concussion education training
session, sport, number of years of experience as a college
varsity athlete, and personal history of concussions. It
was important to examine this because the data may show
which factors affect concussion knowledge in athletes, and

2
allow Team Physicians and Certified Athletic Trainers to
address these factors during the preparticipation exam if a
lack of concussion knowledge is found.
The 2004 National Athletic Trainers’ Association
(NATA) Position Statement on Management of Sport Related
Concussion defines a concussion as a mild Traumatic Brain
Injury (mTBI) which can either be diffuse or focal in
nature.2 Another definition of a concussion was written in
the Zurich Consensus document3 at the Third International
Conference on Concussion in Sport held in 2008. This
definition is as follows: “a concussion is defined as a
complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces.”3 However, the
most recent definition of a concussion was given by the
American College of Sports Medicine (ACSM)1 article entitled
“Concussion (Mild Traumatic Brain Injury) and the Team
Physician: A Consensus Statement.” The ACSM defines a
concussion as a pathophysiological process that affects the
brain induced by direct or indirect biomechanical forces.
All of these definitions are very similar and accurately
define a concussion.
The prevalence of reported concussions is very high.
However, there are even a higher number of undetected and
undiagnosed concussions. According to Bloom et al,4 the

3
number of diagnosed concussions each year is thought to be
much lower than the actual rate of incidences. The
researchers found that the average number of concussions a
male sustained in one year was 3.39, while the average
number of diagnosed concussions per year was 0.36. The
results show that males suffer more concussions that were
undiagnosed. A very similar trend was found in the female
subjects as well. The researchers stated that recognition
and correct diagnosis of a concussion is one of the most
difficult obstacles in the sports medicine field.4
Therefore, a significant stress must be put on recognizing
the signs and symptoms and using an effective diagnostic
technique. Concussions can occur in almost any activity or
sport, including both female and male sports. Male athletes
are susceptible to concussions because of aggressive and
faster pace of play, while females are at a high risk
because of their smaller physical size and decreased
cervical muscular strength.5
The Zurich Consensus Statement on Concussion in Sport3
has also written recommendations for initial assessment and
diagnosis of a concussion. The authors stated that when
there are any signs that an athlete has sustained a
concussion the athlete should be: 1) safely removed from
activity, 2) immediately evaluated onsite, 3) a concussion

4
evaluation tool should be used as soon as possible, 4)
constantly monitored and not left alone during the
remainder of the athletic event, and 5) if the athlete is
diagnosed with a concussion he/she should not be allowed to
return to play the same day.3 Using these recommendations
and evaluation techniques aids in the diagnosis and
management of concussions.
Notebaert and Guskiewicz6 conducted a study that
investigated the current trends in concussion assessment
and management among Certified Athletic Trainers who were
randomly emailed through the National Athletic Trainers’
Association database.

The main results of the survey

included: 95% of AT’s use a clinical evaluation, 85% use
symptom checklists, and 18% use neurocognitive testing to
assess concussions. Using this information, the researchers
concluded that while there are many different methods to
assess and manage a concussion, a multifaceted approach
must be used.6 This article demonstrates that even though
diagnosis can be difficult, recognizing the mechanisms of
injury, utilizing a symptom checklist, performing a
clinical evaluation, and using a neurocognitive examination
are all elements that should be implemented so that a
correct diagnosis can be made and effective management can
begin.

5
The ACSM Consensus statement1 also has guidelines for
return to play criteria for concussed athletes. The biggest
guideline is that a concussed athlete is never allowed to
return to activity the same day as diagnosis. The other
return to play guidelines include that all athletes must be
asymptomatic, no return of symptoms during strenuous
activity or cognitive effort, and neurocognitive testing
should be back to baseline results.
The results of this study will inform health care
professionals who deal within the athletic population, more
specifically team physicians and Certified Athletic
Trainers, what factors affect concussion knowledge the
most. This will help Team Physicians and Athletic Trainers
in the recognition of these factors before the sports
season begins and allow them to be addressed so that
concussion knowledge can be increased.

6

METHODS

The purpose of the study was to examine factors that
affect concussion knowledge in collegiate varsity athletes.
Factors that were examined include participation in a
concussion education training session, whether the athlete
played football or not, number of years of experience as a
college varsity athlete, and personal history of
concussions. This section will include the following
subsections: research design, subjects, instruments,
procedures, hypotheses, and data analysis.

Research Design

A descriptive design was used for this study. The
independent variables were concussion education training,
experience in a varsity sport, sport, and personal history
of concussions. Education training had two levels – varsity
athletes with concussion education training and varsity
athletes without concussion education training. Experience
in a varsity sport had five levels – 1 year, 2 years, 3
years, 4 years, and 5 years. Sport had two levels –
football athletes and non-football athletes. History of

7
concussions had two levels – athletes with no diagnosed
concussions and athletes with one or more diagnosed
concussions. The dependent variable was the knowledge score
as measured by the Concussion Knowledge Survey (Appendix
C1). The strength of this study was the reliability and
validity of the concussion knowledge survey.

Subjects

The survey was distributed to 500 male and female
varsity student-athletes from four colleges and
universities in all three NCAA divisions and NAIA division.
All subjects were current members of a varsity athletic
team at a Division I, II, III, or NAIA collegiate
institution. Participation in the study was voluntary based
upon completion of the survey. The study was approved by
the Institutional Review Board (Appendix C2) at California
University of PA.

Preliminary Research

A panel of experts was organized before any research
was conducted. The panel consisted of five Certified
Athletic Trainers with experience and knowledge of

8
concussions and survey construction. The panel members were
sent the Concussion Knowledge survey and instructions on
their responsibilities regarding the survey. The panel
members reviewed the survey instrument and cover letter.
They added to the content validity and made any
recommendations for improvement. After reviewing the
survey, the panel members provided critiques and changes
that will be reviewed for revision. Necessary changes were
made to the survey based on critiques by panel of experts.

Instruments

The Concussion Knowledge survey (Appendix C1) was
created by the researcher for the purpose of testing
concussion knowledge. The format and ideas for this survey
are based off of five studies in which concussion knowledge
was tested in different populations.7-11 The survey was
created electronically via www.surveymonkey.com. The
subjects were asked to complete demographic information
including age, varsity sport, years of experience at NCAA
varsity sport, what division their college institution is,
whether they have participated in a concussion education
training session, what type of training session it was, and
their personal history of concussions. Additional questions

9
tested the subject’s knowledge of concussions, signs and
symptoms, diagnosis, management, treatment, long term
effects, neurocognitive testing, and return to play
criteria. The entire survey took approximately 15 minutes
to complete.

Procedure

The researcher contacted Athletic Directors at various
NCAA Division I, II, III, and NAIA collegiate institutions
to obtain written consent and permission to use their
varsity athletes in this study. Once obtaining approval
from four Athletic Directors, one at each NCAA division and
NAIA division, the study was reviewed by the California
University of Pennsylvania Institutional Review Board
(IRB). Following approval, an email was sent out to all
Athletic Directors of the participating institutions to
forward to all athletes currently participating in a
varsity sport. The email was sent to the subjects via the
Athletic Director with a Cover Letter (Appendix C3)
explaining the purpose and significance of the study. A
link on the cover letter provided the NCAA varsity athletes
with direct access to begin the survey. Informed consent
was implied when the subject clicked on the link at the

10
bottom of the cover letter. One additional email was sent
one week after the initial one as a reminder. There was no
obligation of the subjects to participate. All subjects who
completed the survey remained anonymous with no way to
trace answers back to one subject. The risk was minimal in
this study. The possible risk of harm associated with this
knowledge research was psychological and dignitary in
nature. Since the responses of each individual were
confidential, the risk posed is small. Gathered data was
analyzed in terms of the hypotheses.

Hypotheses

The following hypotheses were based on the
researcher’s intuition and on a review of the literature.
1.

Varsity athletes with concussion education
training will score higher on the concussion
knowledge test than varsity athletes without
training.

2.

Concussion knowledge will increase with greater
years of collegiate experience as a varsity
athlete.

11
3.

Athletes with a history of concussions will score
higher on the concussion knowledge test than
athletes with no history of concussions.

4.

Football players will score the highest on
concussion knowledge test among all sports.

Data Analysis

All data was analyzed by SPSS Version 18.0 for
Windows at an alpha level of 0.05. An independent t-test
was used to analyze Hypotheses 1, 3, and 4 to determine if
they significantly affect concussion knowledge. A
correlation was used to analyze Hypothesis 2. This
determined if there was any significant relationship
between the number of years as a varsity athlete and the
score on the concussion knowledge survey.

12

RESULTS

The purpose of this study was to examine factors that
affect concussion knowledge in collegiate varsity athletes.
The data was obtained using a survey created by the
researcher. This section contains the following
subsections: Demographic Information and Hypothesis
Testing.

Demographic Information

The Concussion Knowledge Survey was sent to all
student-athletes at the four participating collegiate
institutions. A total of 75 surveys were returned with 67
fully completed. The sample consisted of collegiate
athletes from Division II California University of
Pennsylvania (n=20), NAIA Goshen College (n=41), and
Division III Penn State Fayette (n=6). No surveys were
returned from Division I Indiana University (n=0). All
participants were 18 years of age or older. Table 1
represents the gender classification of participants.

13
Table 1. Gender Classification
Classification
Frequency
Male
26
Female
41

Percent
38.8
61.2

Table 2 represents the number of varsity athletes who had
participated in a concussion education training session.
Table 2. Participation in Concussion Education Training
Classification
Frequency
Percent
Participated
17
25.4
Not Participated
50
74.6

Table 3 represents the number of varsity athletes who
participated in football and all other sports (some
athletes participated in multiple sports).
Table 3. Sport Classification
Classification
Frequency
Football
7
All other sports
55
Soccer
16
Volleyball
9
Track and field
8
Basketball
7
Softball
7
Tennis
4
Baseball
2
Swimming
2

Percent
11.3
88.7
25.8
14.5
12.9
11.3
11.3
6.5
3.2
3.2

Table 4 below represents the classification of years of
experience as a varsity athlete.

14
Table 4. Years of Varsity Athlete Experience Classification
Classification
Frequency
Percent
1 year
18
33.3
2 years
16
29.6
3 years
11
20.4
4 years
8
14.8
5 years
1
1.9

Table 5 represents the number of athletes with a previous
personal history of concussions.
Table 5. History of Concussions
Classification
Frequency
No previous history (0)
49
Previous history (1+)
18

Percent
73.1
26.9

The Concussion Knowledge Survey was used to test the
athlete’s knowledge of concussions. Each survey was graded
as an exam and was worth 67 points with the final score
determining the athlete’s knowledge score. Each correct
answer was given 1 point, while each incorrect answer was
awarded 0 points. The athlete’s score was then divided by
the total possible points (67) and given a percentage with
100% being a perfect score, much like a classroom exam. The
following table (Table 6) shows the range of scores in
percentages.
Table 6. Concussion Knowledge Scores
Classification
Frequency
90-100%
23
80-90%
25
70-80%
15
60-70%
3
<60%
1

Percent
34.3
37.3
22.4
4.5
1.5

15

Hypothesis Testing

The following hypotheses were tested in this study.
All hypotheses were tested with a level of significance set
at α ≤ 0.05.
Hypothesis 1:

Varsity athletes with concussion

education training will score higher on the concussion
knowledge test than varsity athletes without training.
Conclusion: An independent-samples t-test was
calculated comparing the mean concussion knowledge score of
varsity athletes with concussion education training to the
mean concussion knowledge score of varsity athletes with no
concussion education training. No significant difference
was found (t = 1.712, p > .05). The mean score of the
athletes with training (m = 88.2, sd = 8.47) was not
significantly different from the mean score of the athletes
without training (m = 83.6, sd = 9.65). This is represented
in Tables 7 and 8 below.
Table 7. Independent t-test group statistics: Hypothesis 1
Classification
N
Mean
Std. Deviation
Training session
17
88.2
8.47
No training
55
83.6
9.65

16
Table 8. Independent t-test: Hypothesis 1
Classification
t
df
Percentage (Equal
Variances assumed)
1.712
65

Hypothesis 2:

Sig.(2-tailed)
.092

Concussion knowledge will increase with

greater years of collegiate experience as a varsity
athlete.
Conclusion: A Pearson correlation was calculated
examining the relationship between years of experience as a
varsity athlete and concussion knowledge score. A weak
correlation that was not significant was found (r = -.139,
p > .05). Years of collegiate varsity experience is not
related to concussion knowledge score. This can be seen in
Table 9 and Graph 1 below.
Table 9. Pearson Correlation: Hypothesis 2
Classification
Years of Exp.
Yrs of exp
Pearson Cor.
1
Sig. (2-tailed)
N
66
Score (%)
Pearson Cor.
-.139
Sig. (2-tailed)
.267
N
66

Score(%)
-.139
.267
66
1
67

17
Graph 1.

Hypothesis 3: Athletes with a history of concussions
will score higher on the concussion knowledge test than
athletes with no history of concussions.
Conclusion: An independent-samples t-test was
calculated comparing the mean concussion knowledge score of
varsity athletes with a personal history of sustaining a
concussion to the mean concussion knowledge score of
varsity athletes with no personal history of a concussion.
A significant difference was found (t = -3.708, p < .05).
The mean score of the athletes with a history of
concussions (m = 91.3, sd = 5.47) was significantly higher

18
than the mean score of the athletes with no history of
concussions (m = 82.4, sd = 9.59). This is represented in
Tables 10 and 11 below.
Table 10. Independent t-test group statistics: Hypothesis 3
Classification
N
Mean
Std. Deviation
No History
49
82.4
9.59
History
18
91.3
5.47

Table 11. Independent t-test: Hypothesis 3
Classification
t
df
Percentage (Equal
Variances assumed)
-3.708
65

Sig.(2-tailed)
<.05

Hypothesis 4: Football players will score the highest
on concussion knowledge test among all sports.
Conclusion: An independent-samples t-test was
calculated comparing the mean concussion knowledge score of
collegiate varsity football players to the mean concussion
knowledge score of collegiate varsity athletes in all other
sports.

No significant difference was found (t = 1.361, p

> .05). The mean score of the football athletes (m = 89.3,
sd = 6.24) was not significantly different from the mean
score of the all other sports athletes (m = 84.1, sd =
9.95). This is represented in Tables 12 and 13 below.
Table 12. Independent t-test group statistics: Hypothesis 4
Classification
N
Mean
Std. Deviation
Football player
7
89.3
6.24
All other sports
55
84.1
9.95

19
Table 13. Independent t-test: Hypothesis 4
Classification
t
df
Percentage (Equal
Variances assumed)
1.361
60

Sig.(2-tailed)
.179

20

DISCUSSION

This study has produced findings related to the
factors affecting concussion knowledge in varsity
collegiate athletes. The following section will discuss
these findings and is divided into the following
subsections: Discussion of Results, Conclusions, and
Recommendations.

Discussion of Results

This study focused on factors that could affect
concussion knowledge in collegiate varsity athletes.
Factors that were examined were participation in a
concussion education training session, whether the athlete
played football or not, number of years of experience as a
college varsity athlete, and personal history of
concussions.
The researcher’s first hypothesis was that varsity
athletes with concussion education training would score
higher on the concussion knowledge test than varsity
athletes without training. There was no previous research
published or identified on the effectiveness of concussion

21
education training for collegiate athletes. Based on the
researchers own experiences and intuition, it was thought
that athletes with a concussion education training session
would score higher on the concussion knowledge test. It was
found that the athletes who reported participating in
concussion education training did score higher on the
concussion knowledge test. However, the difference was not
significant and does not support this hypothesis. With the
lack of significance to show that concussion education
training increases knowledge of concussions, the results do
not support the research conducted by O'Donoghue et al7.
O’Donoghue et al7 found that coaches who attended a workshop
on concussions scored significantly higher on their
concussion knowledge test. The results also do not support
the findings of Goodman et al.12 Goodman et al12 conducted a
study to determine the effectiveness of a computer game in
increasing youth hockey athletes knowledge of concussion
symptoms. There was a significant difference found in those
youth athletes who had participated in the Symptom Shock
computer game and those who had not.
The second hypothesis examined in this study stated
that concussion knowledge will increase with greater years
of collegiate experience as a varsity athlete. The
researcher hypothesized that the athletes with more years

22
as a varsity athlete would have more experience around
concussions than athletes with fewer years at the
collegiate level. The researcher also hypothesized that
with greater experience comes greater knowledge.
Concussions occur in all sports, so an athlete with four
years of experience would have witnessed more concussions
than an athlete with one year of experience and therefore
have increased knowledge. Surprisingly, it was found that
not only was there no significant difference in the
correlation between the years as a varsity athlete and the
concussion knowledge score, but there was also a weak
negative correlation found. This means that on average,
athletes with fewer years of varsity experience scored
higher than athletes with more years of experience.
The third hypothesis stated by the researcher was that
athletes with a history of concussions will score higher on
the concussion knowledge test than athletes with no history
of concussions. It was thought that athletes with a history
of sustaining a concussion would be more familiar with the
signs and symptoms, management, and return to play criteria
of concussions thus increasing their overall knowledge.
There is no previous research identified that has directly
studied the effect that previous history of concussions has
on the collegiate athlete’s knowledge of concussions. In

23
this study, it was found that collegiate athletes with a
personal history of concussions scored significantly higher
compared to the collegiate athletes without a personal
history. This supports the researcher’s hypothesis. These
results also coincide with results found by O’Donoghue et
al7 in which high school coaches’ knowledge of concussions
was tested. O’Donoghue7 found that coaches with a history of
concussions scored significantly higher in concussion
knowledge. However, in a study conducted by Gourley et al8
that examined youth athletes knowledge of concussions, no
significant difference was found between youth athletes who
reported having their “bell rung” and those who did not.
The researcher’s final hypothesis stated that football
players would score the highest on the concussion knowledge
test among all sports. Crisco et al13 conducted a study to
determine the frequency and location of head impacts on
football players during one season and found that the total
number of hits a player received during one season varied
by team, type of athletic event (practice, game, etc), and
position; and, the maximum number of head impacts ranged
from 1022 to 1444 per season. Crisco concluded the type of
session and position influences the frequency and location
of head impacts. This study indicates that the head impacts,
especially repeated impacts, are occurring at an alarmingly

24
high rate and are a main mechanism of injury for a
concussion. Based on the researcher’s intuition,
experience, and the study conducted by Crisco, it was
thought that football players are at the highest risk of
sustaining concussions and also have the highest incidence
rates, so they would be the most familiar with concussions
and would therefore have the highest scores on the
concussion knowledge test. It was found that football
players did score higher on the test when compared to all
other sports. However, the scores were not significantly
higher.

Conclusions

The results of this study both support and oppose the
results of previous studies. The overall results indicated
that participating in a concussion education training
session, having greater years of experience as a collegiate
varsity athlete, and being a collegiate football player do
not significantly impact concussion knowledge, but having a
personal history of concussions does significantly increase
concussion knowledge. Based on the results of this study,
it may be suggested that concussion education training
needs to be improved and should be a focus before the

25
sports season begins. If the concussion education training
is improved and completed, it should have a positive,
significant effect on concussion knowledge.

Recommendations

The purpose of this study was to identify what factors
affected concussion knowledge in collegiate varsity
athletes. After reviewing the results, one recommendation
would be to increase response rate. This could be
accomplished by a greater number of collegiate institutions
participating in the study. Also, decreasing the number of
steps it took to get the email with the cover letter and
link to the survey to the athletes could enlist more
participation. Another recommendation would be to implement
concussion education programs into collegiate institutions.
Every college athlete should be shown a video or given a
lecture by a Certified Athletic Trainer before every sports
season. The last recommendation would be to have nonathletes participate in the study and to compare the
concussion knowledge scores of athletes to non-athletes.
This could determine if athletes have a significantly
higher knowledge of concussions.

26
REFERENCES
1.

Herring SA, Cantu RC, Guskiewicz KM, Putukian M,
Kibler WB. Concussion (Mild Traumatic Brain Injury)and
the Team Physician: A Consensus Statement — 2011
Update. Medicine & Sciece in Sports & Exercise [serial
online]. 2011;43(12):2412-2422. Available at:
www.acsm.org

2.

Guskiewicz KM, Bruce SL, Cantu RC, et al. National
Athletic Trainers’ Association Position Statement:
Management of Sport Related Concussion. J. Athletic
Training [serial online]. 2004;39(3):280-297.
Available at: www.journalofathletictraining.org.

3.

McCrory P, Meeuwisse W, Cantu R, et al. Consensus
Statement on Concussion in Sport: The 3rd
International Conference on Concussion in Sport Held
in Zurich, November 2008. J. Athletic Training [serial
online]. July 2009;44(4):434-444. Available from:
SPORTDiscus with Full Text, Ipswich, MA. Accessed
September 29, 2011.

4.

Bloom GA, Loughead TM, Shapcott EJ, Johnston KM,
Delaney JS. The prevalence and recovery of concussed
male and female collegiate athletes. European Journal
of Sport Science. 2008;8(5):295-303.

5.

Gessel LM, Fields SK, Collins CL, Dick RW, Comstock
RD. Concussions among United States high school and
collegiate athletes. J. Athletic Training [serial
online]. 2007;42(4):495-503. Available at:
www.journalofathletictraining.org.

6.

Notebaert AJ, Guskiewicz KM. Current trends in
athletic training practice for concussion assessment
and management. J. Athletic Training [serial online].
2005;40(4):320-325. Available at:
www.journalofathletictraining.org.

7.

O’Donoghue EM, Onate JA, Van Lunen B, Peterson CL.
Assessment of high school coaches’ knowledge of sportrelated concussions. Athletic Training & Sports Health
Care [serial online]. 2009;1(3):120-132. Available at:
atshc.com

27
8.

Gourley MM, Valovich McLeod TC, Bay RC. Awareness and
recognition of concussion by youth athletes and their
parents. Athletic Training & Sports Health Care
[serial online]. 2010;2(5):208-218. Available at:
atshc.com

9.

Cusimano MD. Canadian minor hockey participants’
knowledge about concussion. The Canadian J.
Neurological Sciences [serial online]. 2009;36(3):315320.

10.

Rosenbaum AM, Arnett PA. The development of a survey
to examine knowledge about and attitudes toward
concussion in high-school students. J. Clinical and
Experimental Neuropsychology [serial online].
2010;32(1):44-55. Available at:
http://www.psypress.com/jcen

11.

Guilmette TJ, Malia LA, McQuiggan MD. Concussion
understanding and management among New England high
school football coaches. Brain Injury [serial online].
2007;21(10):1039-1047

12.

Goodman D, Bradley NL, Paras B, Williamshon IJ,
Bizzochi. Video gaming promotes concussion knowledge
acquisition in youth hockey players. J. Adol.
2006;29:351-360.

13.

Crisco JJ, et al. Frequency and location of head
impact exposures in individual collegiate football
players. J. Athletic Training [serial online].
2010;45(6):549–559. Available at: www.nata.org/jat

28

APPENDICES

29

APPENDIX A
Review of Literature

30

REVIEW OF LITERATURE

Mild traumatic brain injuries, more commonly known as
concussions, have become a hot topic in the athletic and
medical communities. Currently, there is little information
about what student-athletes know about concussions. Most
research thus far has been focused on educating allied
health and medical professionals such as athletic trainers
and team physicians in how to effectively recognize,
diagnose, and treat concussions with an emphasis on return
to play criteria. However, the significance of examining
athlete’s knowledge of concussions, most specifically the
causes, signs and symptoms, serious long-term effects,
return to play criteria, as well as the role of the athlete
throughout the entire process has not been published or
identified. The purpose of the study was to examine factors
that affect concussion knowledge in collegiate varsity
athletes. Factors that were examined include participation
in a concussion education training session, sport, number
of years of experience as a college varsity athlete, and
personal history of concussions. Examining the many factors
that can affect athlete’s knowledge of concussions, as well
as assessing athlete’s overall knowledge of concussions,

31
determined if concussion education is needed and helped in
the recognition of signs and symptoms, the diagnosis of
concussions, the compliance of the athletes, and the
prevention of negative long term effects
Therefore, the purpose of this literature review is to
inform the reader and gain a greater understanding of
concussions. This will be accomplished in the following
sections: Concussions, Recognition, Management and
Neurocognitive Performance, Long Term Effects, and Return
to Play.

Concussions

The understanding of the medical community in regards
to the best practices in evaluating and managing
concussions is varied for several reasons. Reasons include
the difficulty in researching the pathophysiology of brain
injury, variation in the presentation of concussed
athletes, and the varied recommendations provided by
position statements from various medical organizations.
This section of the literature review is intended to inform
the reader about the definition of a concussion, the impact
of a concussion on the brain, the possible mechanisms of

32
injury, and the prevalence rate of concussions in
athletics.

Definition
The 2004 National Athletic Trainers’ Association
(NATA) Position Statement on Management of Sport Related
Concussion defines a concussion as a mild Traumatic Brain
Injury (mTBI)which can either be diffuse or focal in
nature.1 Focal injuries are more severe and include
hematomas and hemorrhages in the brain, but are very
uncommon in sports. Diffuse brain injuries are more
commonly seen in sports and are usually referred to as a
concussion, sports concussion, and/or mTBI.1
The American College of Sports Medicine2 takes their
definition of a concussion from the U.S. Center for Disease
Control and Prevention (CDC). The CDC defines a concussion
as a “complex pathophysiologic process affecting the brain,
induced by traumatic biomechanical forces secondary to
direct or indirect forces to the head”.2 However, the most
widely known and unanimously agreed upon definition of a
concussion was written in the Zurich Consensus document3 at
the Third International Conference on Concussion in Sport
held in 2008. This definition is very similar to the CDC
definition and is as follows: “a concussion is defined as a

33
complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces.”3

Impact on the Brain
The brain is a complex vital organ that requires an
extensive amount of glucose to function effectively and be
able to process cognitive skills. Any force exerted on the
brain during a concussion can cause cell deformation,
cellular membrane disruption, and ionic imbalances in the
brain.4,5 During this type of brain injury, no structural
damage is incurred by the cell. However, at a cellular
level, there is a large exodus of potassium ions coupled
with an influx of calcium ions. The ionic imbalance
increases the demand for energy (ATP) production to correct
the damage. An increase in ATP demand causes an increase in
glucose metabolism, meaning glucose in the brain is being
used faster and results in an energy crisis.4
As stated earlier, glucose is the main fuel the brain
uses to cognitively function. Thus, when a mTBI occurs and
most of the glucose is being used to correct the tissue
damage, a very small amount of fuel is left for the brain
to function correctly and at its normal level. Damage to
the brain can be caused by several different mechanisms of
injury.

34
Mechanisms of Injury
According to the NATA position statement1, a sports
related concussion most often results from a quick
acceleration and deceleration mechanism, either in a linear
or rotational plane when the head hits a stationary object
or is hit by moving object. This rapid momentum change from
acceleration to deceleration causes the brain to incur
damage.1 Any mechanism of a concussion causes the brain to
experience compressive, tensile, or shear forces.1 A
compressive force involves a crushing of brain tissue,
wherein no additional impact can be absorbed. A tensile
force involves stretching of brain tissue. A shearing force
involves the stretching of the tissue in opposite
directions. Tensile and shear force concussions are
considered more severe than compressive force concussions
because the tissue can withstand compressive forces easier
than stretching forces.1
Meehan et al6 wanted to analyze the mechanisms of
injury of concussions with the highest occurrence, most
common symptoms, and management of concussions in high
school athletes.

The population included high school

athletes who had sustained a sports-related concussion in
the 2008-2009 school year. The results of this study that
pertained to the mechanisms of injury were the following:

35
contact with another player (76.2%) was the highest
occurring mechanism of injury, contact with the ground was
second (15.5%), and contact with another surface was third
most common (7.7%). The specific kind of contact that
occurred the most was head to head contact at 52.7%.6
Criso et al7 conducted a study to determine the
frequency and location of head impacts on football players
during one season. The population included 188 collegiate
football players. There were numerous results that the
researchers obtained through this study.

The total number

of hits a player received during one season varied by team,
type of athletic event (practice, game, etc), and position.
The maximum number of head impacts ranged from 1022 to 1444
between the three teams tested while linemen and
linebackers had the largest number of hits per practice and
game. Offensive lineman had a higher percentage of hits to
the front of the helmet while quarterbacks had a higher
percentage of impacts to the back of the helmet.

There was

also a much higher average amount of hits per game than per
practice for each team.

The researchers concluded that the

type of session and position influences the frequency and
location of head impacts.7 This study indicates that head
impacts, especially repeated impacts, are occurring at an
alarmingly high rate and are a main mechanism of injury for

36
a concussion. The study also suggests why football has been
shown to have a very high incidence rate of concussions.

Incidence Rates
Concussions can occur in contact and non-contact
sports, as well as in both females and males. According to
the University of Pittsburgh Department of Neurological
Surgery,8 there are 1.6 million sports-related concussions
occurring each year. It is also estimated that an athlete
playing in a contact sport has a 19% chance of suffering a
concussion sometime in his/her career. Thirty four percent
of high school athletes have had at least one concussion
and 20% have had multiple.8 This informative article showed
how prevalent concussions are in the athletic population
and that the risk of sustaining one is very high. This
section investigates the prevalence rates among different
sports in high school, collegiate, and professional
settings, as well as between female and male athletes.
Gessel et al9 conducted a study to determine the
prevalence of concussions and compare the rates among the
high school and collegiate settings.

The population of

this study included high school and collegiate athletes.
The researchers analyzed two injury surveillance programs
to determine the prevalence of concussions and any patterns

37
associated within the data. The results were as follows:
concussions consisted of 8.9% of all high school injuries
and 5.8% of collegiate injuries, football and soccer had
the highest incidence rate in both high school and college,
and females had a higher rate of concussions in the high
school setting. The researchers also found that college
athletes had a greater incidence rate of concussions than
high school athletes, but that concussions represented a
higher proportion of all injuries among high school
athletes.9
In a meta-analysis by Tommasone and Valovich,10 the
researchers examined which sports have the highest
incidence rate of concussions. They examined the prevalence
rates of American football, boxing, ice hockey, judo,
karate, tae kwon do, rugby, and soccer in female athletes,
if applicable, and male athletes within the high school,
collegiate, and professional settings. The investigators
reviewed 23 articles that fit all of their criteria and
found that at the high school level for male athletes, ice
hockey had the highest level of incidence while soccer had
the lowest.

However, at the professional level for males,

ice hockey, boxing, and rugby had the highest incidence
rates. For females, in the sports reviewed, tae kwon do had
the highest incidence rates of concussions.10

38
Bloom et al11 conducted an investigation with two main
purposes: 1) to identify if gender affects the number of
concussions an athlete sustains and the amount time until
recovery and 2) to analyze gender and type of sport on
occurrence and time to return to play. The participants
consisted of 170 college student athletes who had sustained
at least one concussion in the previous year at the time of
the study. The participants completed two questionnaires
used to determine their previous history of concussions.
The results were the following: males sustained more
overall concussions than females, males sustained more
unrecognized concussions than females, male basketball
players took longer to return than female basketball
players, and female hockey players took longer than males
to recover.

The researchers concluded that gender does

influence the number of concussions sustained because males
were found to have sustained more concussions overall.
They also concluded that males have more unrecognized
concussions because males are generally less likely to
report symptoms. The authors determined that the main
reason male athletes have a higher incidence rate of
concussions is because of their aggressive and faster pace
of play and participation in collision sports such as
football, hockey, and rugby while the reason females are so

39
susceptible to concussions is because they normally are
smaller physically and have weaker neck strength.11

Recognition

As reported above, the prevalence of reported
concussions is very high. However, there are even a higher
number of undetected and undiagnosed concussions. According
to Bloom et al,11 recognition and correct diagnosis of a
concussion is one of the most difficult barriers in the
medical profession, and the number of diagnosed concussions
each year is thought to be much lower than the actual rate
of incidences.11 Therefore, a significant stress must be put
on recognizing the signs and symptoms and correct diagnosis
techniques. This section will inform the reader on the
signs and symptoms and diagnosis of concussions.

Signs and Symptoms
According to the University of Pittsburgh Medical
Center8 and NATA Position Statement,1 the early signs and
symptoms of a concussion can include the following:
confusion, amnesia, loss of consciousness, headache,
dizziness, nausea, vision problems, vomiting, balance
problems, and tinnitus. Other symptoms that can occur after

40
the initial injury could include memory problems, trouble
sleeping or falling asleep, lack of concentration, fatigue,
personality changes, depression, decrease in ability to
think critically and cognitively, and irritability.8 These
signs and symptoms do not encompass every possible sign or
symptom but are a general list used to help in the
diagnosis and assessment of a sports related concussion.
Frommer et al12 conducted a research study with the
purpose investigating the similarities and differences of
concussion symptoms and return to play time between males
and females. The population for this study consisted of 812
high school athletes who had sustained a concussion in the
previous two school years. Data was collected through an
online injury reporting website and then analyzed by
researchers. The results of this study included the
following: no significant differences between genders in
the number of symptoms reported, males reported amnesia and
confusion more often than females, females reported
drowsiness and noise sensitivity more than males, and no
significant differences were found for time to return to
play. The researchers came to the conclusion that both
genders have the same number of symptoms and time to return
to play, but that there is a difference in the type of
symptoms experienced by each sex.12

41
In a study by Mansell et al,5 the relationship between
a documented history of concussion in an athlete and
experiencing signs and symptoms after sustaining head
trauma was investigated. The population in this study was
made up of 168 collegiate male football players and 33
collegiate female soccer players. The results of this
retrospective study were that only 60% of athletes with no
history of concussions reported signs and symptoms
following a head injury while 80% of athletes with a
history of concussion reported signs and symptoms following
a head injury. The researchers concluded that there is a
significant association between having a history of
concussions and the occurrence of signs and symptoms with a
head injury.5 This study shows that the previously reported
amount of athletes who have sustained a concussion or who
will sustain multiple concussions has a significant effect
on the signs and symptoms.
The researchers of this study wanted to investigate
how individuals who had sustained a concussion could
perform when given a gait/cognition dual task. The subjects
consisted of 10 concussed individuals and 10 healthy
(control) individuals.

The main result of this study was

that there was a significant deficit in performance among
those with a concussion on the first testing day (within 48

42
hours of injury). The researchers concluded from this
deficit that attentional capacity deficits could be a
contributor to gait abnormalities following sustaining a
concussion.13 This study shows that there can be great
variability in concussion symptoms and deficits.
Meehan et al6 analyzed the mechanisms, symptoms, and
management of concussions in high school athletes. The
symptom results of this study were the following: 93.4% of
participants experienced a headache, 74.6% complained of
dizziness, 56.6% had difficulty concentrating, 46.0%
experienced confusion, 37.5% had vision complications,
28.9% had nausea, 26.5% had drowsiness, 24.3% experienced
amnesia, 18.9% complained of sensitivity to noise, 10.7%
had tinnitus, 9.8% experienced irritability, and 4.6% had a
loss of consciousness. Also, the researchers found that
83.4% of participants had no symptoms within one week and
1.5% had symptoms last longer than one month. The
researchers concluded that headache is the most common
symptom experienced and that some athletes with concussions
can have symptoms last up to a month or longer.6

Diagnosis
Diagnosing a sports-related concussion can be
difficult to accomplish because of the many different signs

43
and symptoms and also the fact that sometimes signs and
symptoms may be delayed or not present at all.
The Zurich Consensus Statement on Concussion in Sport3
has also written recommendations for initial assessment and
diagnosis of a concussion. The authors stated that when
there any signs that an athlete has sustained a concussion,
the athlete should be safely removed from activity,
immediately evaluated onsite, a concussion evaluation tool
should be used as soon as possible, the athlete should be
constantly monitored and not left alone during the
remainder of the athletic event, and if the athlete is
diagnosed with a concussion should not be allowed to return
to play the same day.3 Using these recommendations and
evaluation techniques aids in the diagnosis of concussions.
Notebaert and Guskiewicz14 conducted a study that
investigated the current trends in concussion assessment
and management among Certified Athletic Trainers.

The

participants in this study consisted of 927 Certified
Athletic Trainers who were emailed a survey. The main
results of the survey included: 95% of ATC’s use a clinical
evaluation, 85% use symptom checklists, and 18% use
neurocognitive testing to assess concussions. Other results
showed that the American Academy of Neurology was the most
used grading scale, the most important tools for return to

44
play criteria (according to ATC’s surveyed) were clinical
examination, symptoms checklist, and return to play
guidelines, and that only 3% of ATC’s surveyed complied
with the NATA guidelines which supported the use of
symptoms checklist, neurocognitive testing, and balance
testing for managing and return to play decision making.
Using this information, the researchers concluded that a
very low number of ATC’s are following the position
statement on concussions and that while there are many
different methods to assess and manage a concussion, a
multifaceted approach must be used.14 This article
demonstrates that even though diagnosis can be difficult,
recognizing the mechanisms of injury, utilizing a symptom
checklist, performing a clinical evaluation, and using a
neurocognitive examination are all elements that should be
implemented so that a correct diagnosis can be made and
effective management can begin.

Management and Neurocognitive Performance

This section of the literature review is intended to
inform the reader about the management of concussions and
the importance of neurocognitive testing and performance.

45
Management
A study was conducted by Covassin et al15 to determine
the current concussion management and treatment methods
taught to athletic training students in the classroom and
on clinical rotations.

The participants in this study

consisted of 513 athletic training education program
directors and athletic trainers. All participants were
given a survey that asked about education level, years of
experience, preferences of position statements and
concussion grading, and guidelines for concussion
assessment and return to play criteria at their place of
employment.

The results of this study were the following:

61% use the NATA position statement as a guide to
assessment, management, and return to play criteria. The
authors found that the use of neuropsychological testing is
steadily on the increase and its importance in return to
play decisions is being emphasized more.

The overall

conclusion of this research study is that the education of
the assessment and management of concussions needs to be a
multifaceted approach.15 Therefore, the management
information provided in this section will be from the NATA
Position Statement16 because it is what the majority of
Athletic Trainers use and teach with.

46
The NATA Position Statement1 has several
recommendations for management of a sports related
concussion. These consist of instructing the athlete in the
following areas: take Acetaminophen and no other
medications without a doctor’s approval, no intake of
alcohol or any other drugs, resume daily activities as
tolerated but rest as often as possible, no physical
activity until cleared by doctor, continue eating a well
balanced diet, and continually monitor signs and symptoms
and report to medical professional with updates.1
In a study by Guilmette et al,16 the main objective was
to determine high school football coaches’ knowledge of
concussions, the assessment, and management in schools
without a Certified Athletic Trainer. The population for
this research study was New England high school football
coaches. The results of the survey found that the main
source of information about concussion came from coaching
associations and conferences and 70-95% coaches stated that
they would consult with a sports medical professional
before allowing an athlete to return to play. The
conclusions of the researchers was that most football
coaches follow a conservative approach with concussion
management and when making return to play decisions.16 This
suggests that education is not being stressed in importance

47
on non-medical professionals in the area of concussions and
concussion management, but coaches are willing to be
conservative with concussed athletes and at least get a
medical opinion before having an athlete return to play.
The objective of this article written by McGrath17 was
to provide a reference for athletic trainers to use when
advising and communicating to academic colleagues about
concussion treatment for student athletes.

The author

discussed the importance of physical as well as mental rest
when an athlete is trying to recover from a concussion.
The author also gave a multi-layered approach that involves
many school faculty and officials and other medical
professionals in order to aid athletes in their recover
from a concussion.

The main message was that school

officials need to work with the ATC and the athlete to
ensure a balance between cognitive rest and academic work.17

Neurocognitive Testing
Neurocognitive performance refers to how well the
brain can process thoughts, awareness, perception,
reasoning, judgment, and knowledge. A neurocognitive
assessment or test is most often taken through a computer
based program, such as ImPACT, and evaluates the brain’s
ability to function and react. ImPACT has six tests that

48
assess “attention, verbal recognition memory, visual
working memory, visual processing speed, reaction time,
numerical sequencing ability, and learning.”18 As stated
above, one aspect of the assessment, management, and return
to play criteria is utilizing neurocognitive testing. This
section will provide evidence through multiple research
articles on the effectiveness and importance of
neurocognitive testing in return to play decision making.
The use of neurocognitive tests as a concussion tool
is steadily increasing, however there are some questions
regarding the validity and reliability of them. In a
repeated measure study conducted by Broglio et al,19 the
purpose was to determine the test-retest reliability of
three neurocognitive tests (ImPACT, Concussion Sentinel,
and Headminder Concussion Resolution Index tests).

There

were 118 healthy student volunteers who participated in
this study.

The participants took each neurocognitive test

three times (baseline, day 45, and day 50) to test the
reliability. The results showed a low to moderate testretest reliability coefficients. This means that all three
tests have high test-retest reliability.19 The research
proves that the use of neurocognitive assessments as part
of the diagnosis and recognition of concussions is highly
recommended and should be implemented.

49
In a cross-sectional study conducted by Pilan et al,20
the purpose was to examine the relationship between
multiple factors (sex, history of concussions, physical
illness, etc) and responses on two baseline concussion
symptom scales. The population of this study was collegiate
athletes. The results that were found were as follows:
participants with a history of concussions had higher
composite scores, no gender differences were found, and
athletes with acute fatigue, physical illness, or
orthopedic injury had higher scores on both tests. The
researchers concluded that a history of concussions, acute
fatigue, physical illness, or orthopedic injury can
increase baseline scores, so medical professionals need to
be aware of this before allowing athletes to take a
baseline concussion test.20
The main objective of a research study conducted by
Broglio et al21 was to evaluate the relationship between
scores on a neurocognitive test (ImPACT) and the
individual’s reported history of concussions. The
population consisted of collegiate athletes with a history
of concussions and those without a history. The researchers
found no significant differences in the scores between the
groups. Therefore, the conclusions drawn from the results
were that there may be no relationship between a history of

50
concussions and long term neurocognitive test scores or the
deficits are too subtle to be detected on the test.21
The objective of a study conducted by Covassin et al22
was to investigate the current trends of sports medicine
professionals regarding neurocognitive testing as a
baseline for concussion assessment and management. The
population consisted of Certified Athletic Trainers at
college and high school settings.

The results of the

researchers’ online survey were as follows: 94.7% of AT’s
used a baseline neurocognitive test for their athletes,
51.9% used these baseline tests for validity, 95.5%
responded that they would not permit an athlete to return
to play if the athlete’s score was not back to baseline,
and 86.5% of AT’s responded that they would still not allow
an athlete to return to play even if symptom free until
scores were back to baseline while 9.8% responded they
would and 3.8% stated it depended on the importance of the
competition. The researchers concluded that the use of
neurocognitive testing is on the rise but a majority of
ATC’s still rely more on symptoms than on test scores when
making return to play decisions.22
Another important aspect of neurocognitive testing is
using it in return to play decisions. Collie et al23
conducted a study to analyze and compare neurocognitive

51
function in athletes who had recently sustained a
concussion and had symptoms and those who had recently
sustained a concussion but had no symptoms. The population
for this study was Australian male athletes who were then
split into three groups-concussed with symptoms, concussed
without symptoms, and healthy (control). The researchers
found that the concussed athletes with symptoms scored
significantly lower on neurocognitive tests than the other
two groups and that the non-symptomatic group showed a much
larger improvement at the time of reassessment than the
symptomatic group.

The main conclusion of this study is

that athletes must have no symptoms and be back to baseline
scores before any return to play decisions can be made.23
The researchers in the next study were Covassin et
al.18 They wanted to determine if there is an association
between concussion history and the presence of
neurocognitive deficits after sustaining a concussion. The
population used was collegiate student athletes with a
history of concussions. The researchers of this study found
that collegiate athletes who had sustained a concussion and
had a previous history of two or more concussions took
longer to recover verbal memory and reaction time (as
tested on ImPACT) than those athletes with no previous
history. Therefore the study concludes that any medical

52
professional making a decision on an athlete’s return to
play decision should use neurocognitive testing and make
sure it is back to baseline even after symptoms have
disappeared before allowing an athlete to resume play.18
Fazio et al24 conducted a study to determine the
correlation between neurocognitive performance and
concussed athletes with symptoms, concussed athletes
without self-reported symptoms, and a control group of nonconcussed athletes.

The participants of this study

included 192 athletes: 78 concussed with symptoms, 44
concussed without symptoms, and 70 non-concussed (control).
The results were that the concussed athletes without
reported symptoms scored lower on at least four categories
of the ImPACT test than the control group, but scored
higher than the concussed with symptoms group.

The

conclusion from this data is that even if athletes report
no symptoms, they can still be concussed.

The researchers

stress the importance of neurocognitive testing in return
to play decisions because it can detect changes or deficits
that cannot be felt or seen through signs or symptoms.24

53
Long Term Effects

In sections above, it has been suggested that a multifaceted approach to concussion recognition, diagnosis,
assessment, treatment, and return to play criteria. If this
does not happen and athletes return to play sooner than
recommended, long term effects and other complications,
such as post-concussion syndrome and second impact
syndrome, can arise.
Disregarding recommended treatment methods can lead to
long term deficits. In a cohort study performed by Majerske
et al,4 the researchers wanted to determine the effect that
post-concussive activity levels have on symptoms and
performance on neurocognitive tests in student athletes.
This was a regression analysis that tested the athletes up
to 33 days after concussion.
school student athletes.

The population was 95 high

The researchers found those

athletes engaging in high activity levels demonstrated
worse neurocognitive performance (tested through ImPACT).
Therefore, they came to the conclusion that activity level
after sustaining a concussion does affect the occurrence of
symptoms, neurocognitive deficits, and return time.
Medical professionals need to monitor the level of activity

54
of a concussed athlete and modify it, if need be, to ensure
the optimal treatment of a concussion.4
The purpose of this next article written by Garden et
al25 was to determine the relationship between personality
traits and post-concussion symptoms. The population for
this study was 93 healthy participants.

All participants

took a personality test and a post-concussion symptom
inventory.

The results showed a positive significant

correlation between the two tests for a majority of
participants.

For those who did not have a strong

correlation, there was a significant increase in the
negative personality traits such as depression, anxiety,
etc.

The conclusion of the researchers was that

personality traits can attribute to some self-reported
post-concussion symptoms.25
Multiple concussions can have serious long term
effects. Iverson et al26 wanted to determine if there is a
cumulative effect of multiple concussions in athletes. The
population consisted of athletes with a history of three or
more concussions and athletes with no history of
concussions. All participants completed the ImPACT
computerized test before their season and again within 5
days of injury if they sustained a concussion. The results
included the following: the athletes with a history of

55
concussions reported more symptoms at the time of baseline
testing than those with no history, the athletes with a
history of concussions also scored significantly lower on
ImPACT two days post-injury, and athletes with a history of
concussions were 7.7 times more likely to have a severe
drop in memory than those with no history. The conclusion
from this evidence is that athletes with multiple
concussions could have cumulative effects from them.26
Sigurdardottir et al27 wanted to identify postconcussion symptoms and determine any predicting factors of
the symptoms through their research. The participants of
this study included 115 people who had sustained a mild or
severe concussion. The results found by the researchers
were 27.8% of all cases developed post-concussion syndrome
three months after injury and 23.6% at 12 months. They also
found that those subjects with mild to moderate concussions
had a steady decline in post-concussion symptoms over time
while the severe group did not. The researchers overall
conclusion based on their results was that the greater the
severity of concussion, the greater the post-concussion
symptoms will be and how long the last. There were no
differences in post-concussion symptoms regardless of
severity of concussion at the 12 month mark.27

56
The purpose of a prospective study conducted by Yang
et al28 was to determine if there are any clinical signs in
patients with concussions that would be an indicator of
post-concussion symptoms.

There were 180 patients who had

sustained a concussion that participated in this study.
The results were the following: less than 10% of all
participants reported any post-concussion symptoms at two
months post injury and those patients who complained of
physical symptoms at one- and two-weeks post injury were
significantly more likely to develop post-concussion
syndrome.

The researchers concluded that more severe and

persistent physical symptoms can be a predictor of negative
long-term effects and post-concussion syndrome.28
Post concussion syndrome (PCS) needs to be recognized
and treated appropriately. Logan29 published an article to
inform readers about the recognition and treatment of postconcussion syndrome in athletes. The article stated that
the diagnosis of PCS can be very complex and difficult
because the vast amount of signs and symptoms can be
associated with many other disorders. The author also
stressed the importance of cognitive and physical rest in
the treatment of PCS. The conclusion of this article was
that medical professionals need to make sure that athletes

57
with concussions are being monitored closely to ensure
correct recovery.29
Lovell et al30 conducted a study with the purpose of
being able to present sample data regarding a commonly used
concussion symptom list called Post-Concussion Scale (PCS).
The population of this study was young males and females.
The researchers found that the internal validity of the PCS
is very high in healthy and concussed high school and
college-aged persons. They also found that there was no
significant difference in baseline and post-concussive
scores between high school and college participants but
there was a difference between genders with females tending
to report more symptoms. The conclusion of the researchers
is that the PCS is a reliable and valid method of obtaining
symptoms from healthy and concussed high school and college
males and females.30

Return to Play

As stated numerous times in the sections above, many
factors must go into return to play decisions.

This

section will include why this approach is necessary, what
average return to play times are, compliance of return to

58
play guidelines, and what return to play guidelines are
currently being used.
In a study by Broglio et al,31 the objective was to
determine if any neurocognitive impairment is still present
in athletes who have sustained a concussion but no longer
have signs and symptoms. The participants for this study
included 21 NCAA Division I athletes with a history of one
concussion within five to seven days of the study.

The

results found that three days post-concussion, 81% of
athletes had a deficit in at least one area that ImPACT
tests and they also found that once the athletes were nonsymptomatic, 38% still had at least one deficit. Based on
their findings, the researchers concluded that basing
return to play decisions purely on the athlete’s selfreported symptoms is not practical.31 Neurocognitive testing
should be an essential part of the return to play decision
making and is a main reason why using a many different
methods of determining if an athlete is ready to return to
play is needed.
The main objective of a study conducted McClincy et
al32 was to determine the time it took for return to play in
concussed high school and collegiate athletes. The
participants in this study consisted of 104 high school and
collegiate athletes who had sustained a concussion during a

59
sport-related event. The results were the following:
significant differences were found between baseline scores
and two days post injuries in all five areas of ImPACT
test, significant deficits were found at day seven in four
of the content areas, and significant deficits were still
found in the verbal memory content area at day 14 post
injury. Therefore, the conclusion is that neurocognitive
deficits can occur up to seven days and even to 14 days
post injury which stresses the importance of neurocognitive
tests such as ImPACT in return to play decisions.32
The primary objective of a cohort study conducted by
Yard and Comstock33 was to determine if concussed high
school athletes complied with recommended return to play
guidelines. One hundred high schools in the United States
participated in this study. Certified Athletic Trainer’s
submitted injury reports for boy’s and girl’s sports and
the researchers determined if the athletes followed return
to play guidelines set by the American Academy of Neurology
or Prague. The study found that of the 1308 concussions
reported, 40.5% of athletes following the AAM guidelines
and 15% of athletes following Prague guidelines returned to
play to early. Also, it was found that in football, 15.8%
of athletes who sustained a concussion and a loss of
consciousness returned to play in less than one day, and

60
males were much more likely to return to play within one to
two days after sustaining a concussion than females were.
The researchers concluded that too many high school
athletes are not complying with return to play guidelines
and that it is up to coaches, athletic trainers, parents,
etc to see that these athletes follow the guidelines.33

61

APPENDIX B
The Problem

62
STATEMENT OF THE PROBLEM

It is estimated that there are up to 3.8 million
sports-related concussions each year. Concussions have
become a hot topic in sports and medical communities. Most
research thus far has focused on educating allied health
and medical professionals such as athletic trainers and
team physicians in how to effectively recognize, diagnose,
and treat concussions with an emphasis on return to play
criteria. However, the many factors that affect athletes
knowledge of concussions, most specifically the causes,
signs and symptoms, serious long-term effects, and the
return to play criteria, as well as the role of the athlete
throughout the entire process has not been identified. The
purpose of the study was to examine factors that affect
concussion knowledge in collegiate varsity athletes.
Factors that were examined include participation in a
concussion education training session, sport, number of
years of experience as a college varsity athlete, and
personal history of concussions. It is important to examine
this because it showed which factors affect concussion
knowledge in athletes, and therefore allow Team Physicians
and Certified Athletic Trainers to address these factors
before the sports season.

63
Definition of Terms
The following definitions of terms will be defined for
this study:
1)

Concussion – is a mild Traumatic Brain Injury (mTBI)
in which the brain undergoes a physiological
disruption produced by a trauma.

2)

Sports-related concussion – is a concussion sustained
during an athletic event, most often resulting from a
quick acceleration and deceleration mechanism, either
in a linear or rotational plane when the head hits a
stationary object or is hit by moving object.

3)

Neurocognitive testing – is a computerized or
traditional test measuring verbal and visual memory,
complex attention, reaction time, and processing
speed.

4)

Return to play – is the term referred to when an
athlete is evaluated and cleared to return to athletic
participation by a physician.

5)

Varsity athlete – is a student-athlete who is
participating in a NCAA recognized varsity sport.

Basic Assumptions
The following are basic assumptions of this study:

64
1)

The subjects will be honest when they complete their
demographic sheets.

2)

The subjects will answer to the best of their ability
on the survey.

3)

The subjects will have access to a computer and
internet in order to complete the online survey.

4)

The sample obtained will be representative of the
population.

Limitations of the Study
The following are possible limitations of the study:
1)

The survey was completed online and without any
supervision by investigators.

2)

There were many steps that occurred before the
athletes were sent the email with a link to the
survey.

3)

Only varsity athletes with a valid email address were
surveyed.

4)

Athletic Directors and coaches were responsible for
forwarding the email to their athletes.

Significance of the Study
The results of this study will inform health care
professionals who deal within the athletic population, more

65
specifically team physicians and Certified Athletic
Trainers, if conducting a concussion education session for
athletes is an effective way of increasing the athletes’
knowledge in the subject, especially athletes with factors
that cause decreased knowledge. If it is an effective
method and athletes’ knowledge of concussions is increased,
it will aid in the recognition of signs and symptoms, the
compliance of the athletes, and the prevention of negative
long term effects.

66

APPENDIX C
Additional Methods

67

APPENDIX C1
Concussion Knowledge Survey and Answer Key

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82
ANSWER KEY
Recognition
10.A
11.D
12.D
13.C
14.C
15.B
16.D
17.C
18.A
19.A
20.B
21.A
Management
21.A
22.A
23.C
24.C
25.C
26.C
27.A,B
Long Term Effects
28.A
29.A
30.B
31.A
32.A
33.B
Return to Play
34.B
35.B
36.C
37.A
38.B
39.B
40.B, C

83
41.Symptom Checklist
 Feeling in a “Fog”
 Headache
 Feeling Slowed Down
Arthritis
Reduced Breathing Rate
 Sensitivity to Light
Excessive Studying
 Difficulty Remembering
 Difficulty Concentrating
 Dizziness
 Drowsiness
Hair Loss
 Emotional/Irritable
 Loss of memory
 Blurred vision
Chest pain
 Confusion
 Feeling sick
 Trouble sleeping
 Problems studying or doing class work
Scenarios
42. Yes
43. Yes
44. Yes
45. Yes
46. No
47. No

84

APPENDIX C2
Institutional Review Board –
California University of Pennsylvania

85

86

87

88

89

90

91

92

93
From: Athletics Director
Sent: Monday, February 06, 2012 9:30 PM
To: BOY8603 - BOYLE, ANGELA LYNN [mailto:BOY8603@calu.edu]
Subject: Angela Boyle - Athletes participation in survey
Angela,
You have my permission to contact the student athletes.
You will need to send the letter directly to the coaches to
distribute to their student-athletes on their team.
Karen
Karen Hjerpe, PhD
Interim Athletic Director/SWA
California University of PA
250 University Ave., Box #34
California, PA 15419
Phone: 724-938-4167
Fax: 724-938-5421
E-mail: Hjerpe@calu.edu
From: "BOY8603 - BOYLE, ANGELA LYNN" <BOY8603@calu.edu>
Sent: Friday, February 03, 2012 4:35 PM
To: Athletics Director
Subject: Angela Boyle - Athletes participation in survey
Dear Ms. Hjerpe,
My name is Angela Boyle, and I am currently enrolled in the
Graduate Athletic Training Education Program at California
University of PA. I am currently working as a Graduate
Athletic Trainer for Penn State Fayette and am conducting a
research study as part of my Master's degree requirement.
The title of my study is: "Factors That Influence
Collegiate Varsity Athletes Knowledge of Concussions." I am
writing seeking approval to include California University
of PA's athletes in my research study. Participation
includes completion of an electronic survey with all
responses submitted anonymously. With your agreement, I
will send an email to you with a cover letter explaining
further details of the study and a link to the survey. To
protect personal information and email account
distribution, I would ask if you could forward the email to
all of your current student-athletes. By replying to this
email with a "yes," you are agreeing to allow your student
athletes to participate in my study and to distribute the

94
email to them.
Thank you very much for your time, cooperation, and
consideration with this matter. I hope to hear from you
soon.
Sincerely,
Angela Boyle, ATC
Email: boy8603@calu.edu
Cell phone: (574) 274-7518

95

From: tdemant@goshen.edu
To: "BOY8603 - BOYLE, ANGELA LYNN" <BOY8603@calu.edu>
Sent: Monday, March 5, 2012 8:48:42 AM
Subject: Angela Boyle - Survey Research
Angela,
As a current doctoral student myself, I see the value is
participation rates so I would gladly forward your survey
on to our student athletes.
Tim Demant
Athletic Director
Goshen College
Office: 574-535-7491
Cell: 574-238-3585
Fax: 574-535-7531
tdemant@goshen.edu
www.GoLeafs.net
From: "BOY8603 - BOYLE, ANGELA LYNN" <BOY8603@calu.edu>
To: tdemant@goshen.edu
Sent: Thursday, February 23, 2012 11:30:42 AM
Subject: Angela Boyle - Survey Research
Dear Mr. Demant,
My name is Angela Boyle, and I am currently enrolled in the
Graduate Athletic Training Education Program at California
University of PA. I am currently working as a Graduate
Athletic Trainer for Penn State Fayette and am conducting a
research study as part of my Master's degree requirement.
The title of my study is: "Factors That Influence
Collegiate Varsity Athletes Knowledge of Concussions." I am
writing seeking approval to include Goshen College's
athletes in my research study. Participation includes
completion of an electronic survey with all responses
submitted anonymously. With your agreement, I will send an
email to you with a cover letter explaining further details
of the study and a link to the survey. To protect personal
information and email account distribution, I would ask if
you could forward the email to all of your current studentathletes. By replying to this email with a "yes," you are
agreeing to allow your student athetes to participate in my
study and to distribute the email to them.

96

Thank you very much for your time, cooperation, and
consideration with this matter. I hope to hear from you
soon.
Sincerely,
Angela Boyle, ATC
Email: boy8603@calu.edu
Cell phone: (574) 274-7518

97

From: Vince Capozzi<vac12@psu.edu>
Sent: Tuesday, February 07, 2012 10:43 AM
To: "BOY8603 - BOYLE, ANGELA LYNN" <BOY8603@calu.edu>
Subject: Angela Boyle - Athletes participation in survey
Angela,
I am fine with our athletes participating in the survey
should they choose to do so.
Vince
Vince Capozzi
Athletic Director
Assistant Women's Basketball Coach
Penn State Fayette, The Eberly Campus
724-430-4100, Ext. 4515
"(athletics are) a great deal like life in that they teach
that work,
sacrifice, perseverance, competitive drive, selflessness
and respect for
authority is the price that each and every one of us must
pay to achieve
any goal that is worthwhile." –-- Vince Lombardi
From: "BOY8603 - BOYLE, ANGELA LYNN" <BOY8603@calu.edu>
Sent: Friday, February 03, 2012 4:35 PM
To: Athletics Director
Subject: Angela Boyle - Athletes participation in survey
Dear Mr. Capozzi,
My name is Angela Boyle, and I am currently enrolled in the
Graduate Athletic Training Education Program at California
University of PA. I am currently working as a Graduate
Athletic Trainer for Penn State Fayette and am conducting a
research study as part of my Master's degree requirement.
The title of my study is: "Factors That Influence
Collegiate Varsity Athletes Knowledge of Concussions." I am
writing seeking approval to include PSU Fayette's athletes
in my research study. Participation includes completion of
an electronic survey with all responses submitted
anonymously. With your agreement, I will send an email to

98
you with a cover letter explaining further details of the
study and a link to the survey. To protect personal
information and email account distribution, I would ask if
you could forward the email to all of your current studentathletes. By replying to this email with a "yes," you are
agreeing to allow your student athetes to participate in my
study and to distribute the email to them.
Thank you very much for your time, cooperation, and
consideration with this matter. I hope to hear from you
soon.
Sincerely,
Angela Boyle, ATC
Email: boy8603@calu.edu
Cell phone: (574) 274-7518

99

Certificate of Completion
The National Institutes of Health (NIH) Office of Extramural Research
certifies that Angela Boyle successfully completed the NIH Web-based
training course “Protecting Human Research Participants”.
Date of completion: 07/01/2011
Certification Number: 712596

100
Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP, Chair
Dear Angela Boyle:
Please consider this email as official notification that
your proposal titled "Factors That Influence Collegiate
Varsity Athletes Knowledge of Concussions” (Proposal #11057) has been approved by the California University of
Pennsylvania Institutional Review Board as amended, with
the following stipulations:
--The consent form/cover information specifies that
individuals must be 18 years of age or older. The first
question of the survey asks age, but there is no evidence
that the survey then terminates or that the participant is
redirected if they answer that they are 17 or younger (or
other action). Prior to beginning data collection, you must
provide the Board with a statement of what will occur if an
individual answers that they are under 18.
-At various points in the proposal , NCAA and NAIA athletes
are inconsistently listed. Your consent form/cover letter
must explicitly state your target population. You must
provide the IRB with a copy of the consent form/cover
letter with the correct target population listed.
Please provide the information requested prior to beginning
data collection. After this information has been provided
for our records, you may immediately begin data collection.
You do not need to wait for further IRB approval once the
requested information has been submitted.
The effective date of the approval is 4/3/2012 and the
expiration date is 4/2/2013. These dates must appear on the
consent form.
Please note that Federal Policy requires that you notify
the IRB promptly regarding any of the following:

101
(1) Any additions or changes in procedures you might wish
for your study (additions or changes must be approved by
the IRB before they are implemented)
(2) Any events that affect the safety or well-being of
subjects
(3) Any modifications of your study or other responses that
are necessitated by any events reported in (2).
(4) To continue your research beyond the approval
expiration date of 4/2/2013 you must file additional
information to be considered for continuing review. Please
contact instreviewboard@cup.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

102

Appendix C3
Cover Letter

103

4/4/2012
Dear Student Athlete:
My name is Angela Boyle and I am currently a graduate
student at California University of Pennsylvania pursing a
Master of Science in Athletic Training. Part of the
graduate study curriculum is to complete a research thesis
through conducting research. I am conducting survey
research to determine what factors influence collegiate
varsity athlete’s knowledge of concussions. This data will
determine collegiate athlete’s knowledge of concussions or
lack thereof, what factors that potentially influence that
knowledge, and who to focus concussion education on the
most.
The target population is varsity athletes from NCAA
Division I, NCAA Division II, NCAA Division III, and NAIA
institutions; however, your participation is voluntary and
you do have the right to choose not to participate. All
participants must be 18 years or older. You also have the
right to discontinue participation at any time during the
survey completion process at which time your data will be
discarded. The California University of Pennsylvania
Institutional Review Board has reviewed and approved this
project. The approval is effective 04/03/2012 and expires
04/03/2013.
All survey responses are anonymous and will be kept
confidential, and informed consent to use the data
collected will be assumed upon return of the survey.
Aggregate survey responses will be housed in a password
protected file on the CalU campus. Minimal risk is posed
by participating as a subject in this study. I ask that
you please take this survey at your earliest convenience as
it will take approximately 20 minutes to complete. If you
have any questions regarding this project, please feel free
to contact the primary researcher, Angela Boyle at
boy8603@calu.edu. You can also contact the faculty advisor
for this research (Dr. Jamie Weary, DPT, ATC at 724-9385708 or weary@calu.edu). Thanks in advance for your
participation. Please click the following link to access
the survey https://www.surveymonkey.com/s/VD2HNZR.

104

Thank you for taking the time to take part in my thesis
research. I greatly appreciate your time and effort put
into this task.
Sincerely,
Angela Boyle
Primary Researcher
California University of Pennsylvania
250 University Ave
California, PA 15419
(574) 274-7518
Boy8603@calu.edu

105
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ABSTRACT
TITLE:

FACTORS THAT INFLUENCE COLLEGIATE VARSITY
ATHLETES’ KNOWLEDGE OF CONCUSSIONS

RESEARCHER:

Angela Boyle, ATC, PES

ADVISOR:

Dr. Jamie Weary

DATE:

May 2012

PURPOSE:

The primary purpose of this study was to
determine what factors affect concussion
knowledge in collegiate varsity athletes.

Design:

Descriptive Survey

Settings:

Population-Based Survey

Participants:

500 collegiate varsity athletes at the four
participating college institutions. The
final response rate was 67.

INTERVENTIONS: The independent variables were concussion
education training, experience in a varsity
sport, sport, and personal history of
concussions. The dependent variable was the
score on the concussion knowledge test.
RESULTS:

There was significance found in one of the
four hypotheses which indicates that a
previous history of concussions was the only
factor that affected concussion knowledge.
In addition, participating in a concussion
education training session, having greater
years of experience as a collegiate varsity
athlete, and being a collegiate football
player does not significantly impact
concussion knowledge.

CONCLUSIONS:

Based on the results of this study, we can
conclude that concussion education training
is not effective in increasing concussion
knowledge and needs to be improved before
every sports season begins.