i

CONCUSSION KNOWLEDGE AMONG YOUTH PARENTS IN THE
COMMONWEALTH OF PENNSYLVANIA: A SURVEY BASED ON THE SAFETY
ON YOUTH SPORTS ACT

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:
Trevor B. O'Brien

Research Advisor, Dr. Michael Meyer
California, Pennsylvania
2014

ii

iii

ACKNOWLEDGEMENTS

I would first like to thank my thesis chair, Dr.
Michael Meyer, for his guidance and support throughout the
thesis process. Receiving late night emails and phone calls
revealed his dedication and commitment to this project and
I truly appreciated it all. Also I want to thank my
committee members, Vilija Bishop and Dr. Thomas West, for
providing me with their knowledge and feedback on my topic
and research methods. Another thank you is owed to my
program director, Dr. Shelly DiCesaro, for always being
there for a quick question or when something more difficult
came about.
Thank you to my family for always supporting me and
providing me with this opportunity to further my education
at California University of Pennsylvania. I would also like
to thank my loving girlfriend for sticking by my side and
always providing advice and support during the challenging
writing times.
Lastly, to the wonderful group of friends I was able
to meet this year. Without them I am not sure how
successful this year would have been for me. I have made
life long memories and relationships with them and those
will never be forgotten. Thank you all.

iv

TABLE OF CONTENTS
PAGE
SIGNATURE PAGE. . . . . . . . . . . . . . . . . ii
ACKNOWLEDGEMENTS.

. . . . . . . . . . . . . . . iii

TABLE OF CONTENTS. . . . . . . . . . . . . . . . iv
LIST OF TABLES. . . . . . . . . . . . . . . . . vii
INTRODUCTION. . . . . . . . . . . . . . . . . . 1
METHODS. . . . . . . . . . . . . . . . . . . . 6
Research Design. . . . . . . . . . . . . . . . 6
Participants.

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

Preliminary Research. . . . . . . . . . . . . . 8
Instrumentation. . . . . . . . . . . . . . . . 9
Procedures. . . . . . . . . . . . . . . . . . 10
Hypotheses. . . . . . . . . . . . . . . . . . 11
Data Analysis. . . . . . . . . . . . . . . . . 13
RESULTS. . . . . . . . . . . . . . . . . . . . 14
Demographic Data. . . . . . . . . . . . . . . . 14
Hypothesis Testing. . . . . . . . . . . . . . . 18
Additional Findings.

. . . . . . . . . . . . . 23

DISCUSSION. . . . . . . . . . . . . . . . . . . 28
Discussion of Results. . . . . . . . . . . . . . 29
Conclusions. . . . . . . . . . . . . . . . . . 31
Recommendations. . . . . . . . . . . . . . . . 35

v

REFERENCES. . . . . . . . . . . . . . . . . . . 37
APPENDICES. . . . . . . . . . . . . . . . . . . 39
Appendix A: Review of Literature. . . . . . . . . . 40
Introduction.

. . . . . . . . . . . . . . . . 41

Concussion Background. . . . . . . . . . . . . . 42
Signs and Symptoms. . . . . . . . . . . . . . 42
Neurophysiology and Neuropsychology. . . . . . . 44
Second Impact Syndrome and Recurrent Concussions. . 46
Concussions in Adolescents. . . . . . . . . . . . 47
Management and Treatment.
Return-to-Play.

. . . . . . . . . . 47

. . . . . . . . . . . . . . 49

Concussions in Several Contact Sports.

. . . . . . 50

Football. . . . . . . . . . . . . . . . . . 50
Lacrosse. . . . . . . . . . . . . . . . . . 52
Soccer. . . . . . . . . . . . . . . . . . . 53
Education and Awareness. . . . . . . . . . . . . 55
Concussion Knowledge Surveys. . . . . . . . . . 55
Legislative Research. . . . . . . . . . . . . 58
Conclusion. . . . . . . . . . . . . . . . . . 61
Appendix B: The Problem.
Statement of the Problem.

. . . . . . . . . . . . 63

Definition of Terms.
Basic Assumptions.

. . . . . . . . . . . 64

. . . . . . . . . . . . . 64
. . . . . . . . . . . . . . 65

Limitations of the Study.

. . . . . . . . . . . 65

vi

Statement of Significance. . . . . . . . . . . . 66
Appendix C: Additional Methods. . . . . . . . . . . 68
Understanding of Risk of Concussion and Traumatic Brain
Injury Form (C1). . . . . . . . . . . . . . . . 69
Institutional Review Board (C2). . . . . . . . . . 71
Concussion Information Sheet Survey (C3). . . . . . 73
Validity Questionnaire for Panel of Experts (C4). . . 83
Cover Letter to Athletic Directors & Parents (C5).

. 85

REFERENCES. . . . . . . . . . . . . . . . . . . 90
ABSTRACT.

. . . . . . . . . . . . . . . . . . 95

vii

LIST OF TABLES
Table

Title

1

Education Completed by Parent.

.

.

15

2

Size of Student Athletes School.

.

.

16

3

Certified Athletic Trainer.

.

.

16

4

Parent Diagnosed with a Concussion.

.

17

5

Student Athlete Diagnosed with a Concussion. 17

6

Education Completed by Parent & Raw Score.

19

7

Size of School & Raw Score.

.

19

8

Certified Athletic Trainer & Raw Score. .

20

9

One-way ANOVA of ATC on Raw Score. .

.

21

10

Post Hoc Tukey of ATC on Raw Score.

.

21

11

Parent Concussion History & Raw Score.

.

22

12

Student Athlete Concussion History
.

22

& Raw Score.

Page

.

.

.

.

.

.

.

.

13

Awareness of Safety in Youth Sports Act.

14

Learned Something New.

15

Feel Better About Recognition.

.

.

24

.

.

24

.

.

25

viii

16

Signs & Symptom Identification.

.

.

27

1

INTRODUCTION

Sport-related concussion can occur in any sport and
has been shown in high school athletics to account for 8.9%
of all athletic injuries. It is estimated that 1.6 to 3.8
million concussions occur each year and approximately 50%
of those go unreported.1-4 It has been shown adolescent
athletes are more likely to sustain a concussion so the
responsibility of recognizing signs and symptoms falls on
the parents and coaches. Therefore, it is important for
parents and coaches of youth athletes be educated on the
signs and symptoms of a concussion, the best post-injury
treatment plans, and the proper medical professional
clearance before returning to play.
A concussion can be defined as a brain injury
involving complex pathophysiological processes induced by
biomechanical forces affecting the brain.5 Biomechanical
forces may be caused by a blow to the head, face, neck, or
blow to the body resulting in shear forces on the brain.
Concussion sign and symptom domains are: symptoms, physical
signs, behavioral changes, cognitive impairment, and sleep
disturbance, which are summarized in the Consensus
Statement of the 4th International Conference on Concussion

2

in Sport held in Zurich, November 2012.5 Components of these
domains could include headache, feeling in a fog, nausea or
vomiting, dizziness, loss of consciousness, anterograde or
retrograde amnesia, irritability, sadness, anxiousness,
slowed reaction time and difficulty concentrating.5
Understanding the neurophysiology of concussions helps
with explaining to parents or coaches treatment and
management options and can also make them easier to
comprehend. Concussions can be thought of as a two-part
injury, the first being the initial blow to the head and or
body, the second being the inflammatory process, which
accompanies any physical injury. The delayed inflammatory
process following the initial injury could possibly explain
why some signs and symptoms are not immediately present and
go unrecognized.6 Along with suffering from
neurophysiological signs and symptoms, another possible
component often overlooked is the neuropsychological
component. The injured athlete may experience a number of
different long-term and/or psychological issues including
depression, anxiety, psychosocial problems, physical, and
cognitive disturbances, and chronic traumatic
encephalopathy.7
One of the more serious and possibly fatal
consequences of concussions is second impact syndrome. The

3

name was coined from a description written by two
researches, Saunders and Harbaugh8,9, in 1984 on a 19-yearold college football player who suffered a head injury.
Second Impact Syndrome occurs when a concussed athlete
returns to activity and receives a second blow to the head
or body before the original injury has healed. The result
is rapid brain swelling, severe onset of brain trauma
symptoms and in most cases, death. Second Impact Syndrome
reinforces the importance of concussion knowledge among
parents of youth athletes so that life altering or life
threatening situations can be minimized.
Reasoning behind why so many concussions go unreported
every year could be due to parents, coaches, and athletes
not having enough knowledge and awareness of the signs and
symptoms of concussions. A survey study examined the
underreporting of concussion incidence in high school
football players and displayed only 47% actually reported
concussion symptoms to their parent or medical
professional. They were asked to state their reasoning for
not reporting their symptoms: 66% did not think the injury
was significant and 36% did not realize the symptoms they
had were from a concussion.10 Providing more education for
parents, coaches, and athletes is the first step in

4

overcoming the underreporting issue, which in turn will
help with proper management to prevent recurrent injuries.
In May of 2009 the Lystedt Law was passed in
Washington State which requires youth parents, coaches and
athletes be educated on the signs and symptoms of
concussions.11 The law also mandates immediate removal from
the playing field if a concussion is suspected and requires
written clearance from a trained medical professional
before returning to play. Shenouda et al11 administered a
survey study to parents, coaches, and officials of youth
soccer organizations in Washington State in order to
examine the effectiveness of the Lystedt Law. The results
suggested that 96% knew concussions were a form of TBI, 93%
were aware that loss of consciousness does not have to take
place, 98% identified neurological symptoms as concussion
indicators, and 85% were actually aware of the Lystedt
Law.11 The information found in the study revealed benefits
of youth concussion legislation and showed the importance
of parents knowledge on the injury.
The state of Pennsylvania passed the Safety in Youth
Sports Act in 2011 also known as the Pennsylvania Senate
Bill 200/Act 101.12 This bill focuses on interscholastic
athletics and mandates coaches complete an annual
concussion education course. Immediate removal from

5

participation is required for someone displaying signs and
symptoms of a concussion and before return to play the
athlete must have written clearance by a licensed physician
and be completely symptom free.12 In addition, the Safety in
Youth Sports Act requires that athletes and their parents
annually review and sign the Understanding of Risk of
Concussion and Traumatic Brain Injury form (Appendix C1).
Also known as the Concussion Information Sheet, this form
is included in the Pennsylvania Interscholastic Athletic
Association (PIAA) Comprehensive Initial Pre-Participation
Physical Evaluation packet (CIPPE).
There has not been any evidence-based research
published on the Safety in Youth Sports Act or the
Concussion Information Sheet to date. It is important for
both to be evaluated because they could be the only
educational tools utilized by the parent and athlete. In
order to protect young athletes’ brains from injury and
possible long-term consequences, it is imperative to make
sure every aspect of this newly passed legislation provides
the correct resources and guidance to parents, youth
athletes, and coaches.

6

METHODS

The primary purpose of this study was to assess the
concussion knowledge gained from the Concussion Information
Sheet by parents whose youth are involved in athletics in
the Pennsylvania Interscholastic Athletic Association
(PIAA). A survey was distributed in order to evaluate the
parents’ knowledge following review of the Concussion
Information Sheet. The Concussion Information Sheet is part
of the Pennsylvania Senate Bill 200 Act 101, effective in
2012, which states that students participating in
interscholastic athletics and the students’ parent(s) are
required to sign and return acknowledgment of receipt and
review of the Concussion Information Sheet for each year of
participation.12

Research Design

This study utilized a descriptive research design
aimed at analyzing data collected from the developed
survey. Following approval by the Institutional Review
Board (Appendix C2) at California University of
Pennsylvania, an electronic survey formatted on
SurveyMonkey.com was administered to participants in order

7

to evaluate their current knowledge of the Concussion
Information Sheet. The independent variables were:
completed education level by the parent, size of the
student athlete’s school, if the school employs a certified
athletic trainer, concussion history of the parent, and
concussion history of the student athlete. The dependent
variable of this study was the parents’ knowledge score of
the Concussion Information Sheet. The survey used to
measure the dependent variable was administered online
through Surveymonkey.com.

Participants

Participants included in the survey were
parents/guardians of youth athletes competing in the PIAA.
Currently, there are 1,422 schools and over 350,000 student
athletes competing under the PIAA jurisdiction.13 There were
507 surveys sent out to Pennsylvania State Athletic
Directors Association (PSADA) members and there was a total
of 143 participants who completed the survey. It was
assumed that all the athletic directors in the PSADA have
all current emails for the parents associated with their
school. Parents of all student athletes from sports within
the athletic association were analyzed with the exclusion

8

criteria of: not having a child in interscholastic
athletics associated with the PIAA, the parent/guardian
being less than 18 years of age, and/or not completing the
survey questions associated with the Concussion Information
Sheet.

Preliminary Research

A preliminary survey was developed before
Institutional Review Board (IRB) submission in order to
determine the quality and effectiveness of the survey. The
preliminary survey was distributed to faculty members in
the athletic training department at California University
of Pennsylvania. Included were the Graduate Athletic
Training Education Program Director, the Head Athletic
Trainer, and two full-time Athletic Training faculty
members. They were provided with a copy of the Concussion
Information Sheet along with the preliminary survey and
were instructed to evaluate the survey’s construct and
content validity, focusing on their relation to the
information sheet. Any instruction and recommendations were
considered and a final survey was developed.

9

Instrumentation

At the beginning of every school year, each athlete
must turn in the completed PIAA CIPPE before the athletic
season begins. Section 3 of the CIPPE is the Understanding
of Risk of Concussion and Traumatic Brain Injury form, also
known as the Concussion Information Sheet. The one page
document includes information such as defining a
concussion, the signs and symptoms associated with a
concussion, and action to be taken when an individual feels
they or someone else has suffered a concussion.
In order to evaluate the knowledge level of parents in
relation to the Concussion Information Sheet, the
researcher distributed a survey (Appendix C3) to parents of
youth involved in the PIAA. The first page of the survey
was the cover letter explaining the details of the study
and information on informed consent and confidentiality.
The material in the survey covered seven demographic
questions, 12 additional information questions, and 15
questions directly focused on the Concussion Information
Sheet (34 total). The demographic section (1-7) included
age, race/ethnicity, gender, parents’ occupation and
highest level of education. In the additional information
section (8-19), questions included; how many of their

10

children compete in the PIAA, size of the child’s school,
and parent/child history of concussion. Also in this
section there were three questions which focused directly
on the effectiveness of the Concussion Information Sheet
and Safety in Youth Sports Act (10-12). The final section
of the survey focused strictly on the information sheet
itself and included True/False, Yes/No/Don’t Know, and
multiple choice questions (20-34). Question 25 was a sign
and symptom identification question with 22 possible
answers where the parent selected whether or not each
symptom related to a concussion. Questions 20-34 were
scored for a total of 36 possible points. Correct responses
were awarded one point, incorrect/don’t know/somewhat
responses were awarded zero points. An example of the
survey format and questions can be found in Appendix C3
along with the Concussion Information Sheet in Appendix C1.

Procedures

The study was approved by the Institutional Review
Board at California University of Pennsylvania (Appendix
C2). Prior to data collection, an original survey was
distributed to California University of Pennsylvania
athletic trainers to determine content and context

11

validity. The panel of experts were contacted via email
with instructions to complete a validity questionnaire
directed towards the survey (Appendix C4). The PIAA agreed
to distribute the SurveyMonkey link and the cover letter to
all of the athletic directors in the Pennsylvania State
Athletic Directors Association (PSADA). The cover letter
(Appendix C5) was strictly for the athletic directors and
included a brief summary of the study and instructions to
distribute the SurveyMonkey link to the parents of athletes
in their school. Once the Executive Director of the PIAA
distributed the information to the athletic directors, the
survey was available on Surveymonkey.com for two weeks.
After seven days of the survey being available, a follow-up
email was sent to the Executive Director requesting a
reminder email be sent to the athletic directors to
encourage their parents to complete the survey. At the end
of the two week period the survey was closed and data
collection began.

Hypotheses

The following hypotheses were based on previous
concussion survey related research and the researcher’s
intuition based on a review of the literature.

12

1. There will be a difference in knowledge scores of
parents based on completed education level of the
parent.
2. There will be a difference in knowledge scores of
parents based on the size of the student athletes’
school.
3. There will be a difference in knowledge scores of
parents based on whether a school employs a certified
athletic trainer.
4. There will be a difference in knowledge scores of
parents if the parent has a history of concussion.
5. There will be a difference in knowledge scores of
parents if their student athlete has a history of
concussion.

Data Analysis

Results of the survey were collected via
SurveyMonkey.com and transferred into SPSS for data
analysis. Comparative data analysis were used to determine
if data supports the hypotheses. Specifically, a one-way
factorial ANOVA was utilized in order to analyze the
independent variables and their effect on the dependent
variable. Level of significance was set at p ≤ .05.

13

Descriptive statistics were conducted on items 10-12 to
determine if the Concussion Information Sheet and Safety in
Youth Sports Act was useful and effective. For items 20-34,
an overall score was calculated with 36 total possible
points and was the dependent variable in the ANOVA test.
One point was awarded for correct responses and zero points
were awarded for incorrect/don’t know/somewhat responses.

14

RESULTS

The purpose of this research was to assess parents’
knowledge of the Concussion Information Sheet that has been
implemented as part of the Safety in Youth Sports Act.
Various demographic items were used as independent
variables and each participant received an overall
knowledge score, which was the dependent variable. The
following section contains the data collected through the
study and is divided into three subsections: Demographic
Data, Hypothesis Testing, and Additional Findings.

Demographic Data

A total of 192 surveys were completed and returned.
The PIAA executive director sent the survey information to
507 PSADA members. Without knowing how many surveys were
distributed to parents, a rate of return was not
determined. Only 143 surveys were included in the study
following removal of incomplete submissions and submissions
failing to meet the inclusion criteria. There were 92
female (65.7%) and 48 male (34.3%) participants that
completed the survey. Age range varied with 16.1% aged 31-

15

40 (N=23); 62.9% aged 41-50 (N=90); 18.2% aged 51-60
(N=26); and 2.8% 61 and older (N=4). Participant responses
revealed 43.2% being a part of organized coached sports for
ten or more years.
Parents were asked to indicate their highest level of
education completed. Table 1 displays data for highest
level of education completed.
Table 1. Highest Education Level Completed by Parent
N
Percent
Graduated from HS
16
11.3
Completed 1-3 years of
29
20.4
College
Graduated from College
44
31.0
Completed some
17
12.0
Graduate School
Graduated from
36
25.4
Graduate School
Total
142
100.0

It was hypothesized that the size of the student
athlete’s school will have an impact on the parents’
knowledge score. 46% (N=64) of parents indicated their
student athlete belongs to a AA school. Data is displayed
in Table 2.

16

Table 2. Size of Student Athletes’ School
N
Percent
A
21
15.1
AA
64
46.0
AAA
36
25.9
AAAA
3
2.2
Don’t
15
10.8
Know
Total
139
100.0

Participants were asked to indicate whether or not
their son or daughter’s school employs a certified athletic
trainer. It was hypothesized that having an athletic
trainer in a secondary school system will have an impact on
the parents’ knowledge of concussion. Table 3 displays 93%
of participants (N=132) stated “yes”, their student
athlete’s school employs a certified athletic trainer; 1.4%
of participants stated “no” (N=2), and 5.6% of participants
(N=8) did not know if their school employed a certified
athletic trainer.

Table 3. Certified Athletic Trainer
N
Percent
Don’t
8
5.6
Know
Yes
132
93.0
No
2
1.4
Total
142
100.0

17

Table 4 provides the distribution of parents that have
been diagnosed with a concussion. It was a hypothesis that
parents that have been diagnosed with a concussion will
show a difference in knowledge scores compared to parents
who have not been diagnosed.
Table 4. Parent Diagnosed with Concussion
N
Percent
Don’t
3
2.1
Know
Yes
34
23.8
No
106
74.1
Total
143
100.0

It was also asked of the parents to indicate whether
or not their student athlete has ever been diagnosed with a
concussion. Similar to the previous table, it was
hypothesized that if the student athlete has been diagnosed
with a concussion, then the parents’ knowledge score will
be affected; data is displayed in Table 5.
Table 5. Student Athlete Diagnosed with Concussion
N
Valid
Percent
Don’t
1
.7
Know
Yes
52
36.4
No
90
62.9
Total
143
100.0

18

Hypothesis Testing

The following list contains the hypotheses that were
tested in this study. All hypotheses were tested with a
level of significance set at P ≤ 0.05. A one-way factorial
ANOVA was calculated for the effect of the independent
variables on the dependent variable. Each of the hypotheses
were tested separately as their own independent variable.
Hypothesis 1: There will be a difference in knowledge
scores of parents based on completed education level of the
parent. The one-way ANOVA on education level and knowledge
score of the parent was not significant (F(6,135) = 1.614,
p > 0.05). The data suggests that education level completed
by parents of youth athletes does not influence parents’
knowledge as it relates to the Concussion Information
Sheet. The distribution of data is represented in Table 6.

19

Table 6. Education Level Completed & Raw Score
Completed
Raw Score
N
Std.
Education
Mean
Deviation
Graduated from HS
25.44
16
6.271
1 yr of College
26.78
9
2.167
2 yrs of College
22.93
14
11.228
3 yrs of College
26.17
6
2.483
Graduated from
26.89
44
5.195
College
Some Grad School
29.41
17
3.624
Completed Grad
26.50
36
5.906
School
Total
26.50
142
6.095

Hypothesis 2: There will be a difference in knowledge
scores of parents based on the size of the student
athlete’s school. Table 7 displays the distribution of data
between size of school and the parents’ raw score. The oneway ANOVA on this hypothesis was not significant (F(5,133)
= .675, p > 0.05). School size is not a factor in parent
knowledge as it relates to the Concussion Information
Sheet.
Table 7. Size of Student Athletes’ School & Raw Score
School
Raw Score
N
Std.
Size
Mean
Deviation
Don’t
25.79
14
6.796
Know
A
27.90
21
2.827
AA
26.23
64
5.580
AAA
26.39
36
6.813
AAAA
31.67
3
4.163
Other
26.0
1
Total
26.60
139
5.719

20

Hypothesis 3: There will be a difference in knowledge
scores of parents based on whether a school has a certified
athletic trainer or not. Table 8 displays the distribution
of data between a school having a Certified Athletic
Trainer and the parents’ raw score. Table 9 displays the
one-way ANOVA that was calculated as significant (F(2,139)
= 3.212, p < 0.05). Although data suggests significance, it
should be noted that 132 participants answered “yes”, two
answered “no”, and eight answered “don’t know”. As a result
of this distribution, a Post Hoc Tukey statistic was run to
show where the significance is among the distribution.
Table 10 shows these findings.

Table 8. Certified Athletic Trainer & Raw Score
ATC at
Raw Score
N
Std.
School
Mean
Deviation
Don’t
25.50
8
3.665
Know
Yes
26.69
132
5.989
No
15.50
2
14.849
Total
26.46
142
6.112

21

Table 9. One-way ANOVA of ATC
DV-Raw
Type III
Df
Score
Sum of
Squares
Corrected 270.330a
2
Model
Intercept 4455.821
1
ATC
270.330
2
Error
5848.909
139
Total
73708.000
142
Corrected 6119.239
141
Total
a. R Squared = .044 (Adjusted

on Raw Score
Mean
Square

F

Sig.

135.165

3.212

.043

4455.821
135.165
42.078

105.89
3.212

.000
.043

R Squared = .030)

Table 10. Post Hoc Tukey of ATC on Raw Score
(I) (J)
Mean
Std.
Sig.
ATC ATC Difference
Error
DK
Yes
-2.091
2.362
.650

Yes

No

No

9.000

5.128

.189

DK

2.091

2.362

.650

No

11.091

4.621

.046

DK

-9.000

5.128

.189

Yes

-11.091

4.621

.046

Hypothesis 4: There will be a difference in knowledge
scores of parents if the parent has a history of
concussions. Table 11 displays the distribution of parents’
history of concussion and their raw score. The ANOVA test
was not significant (F(2,140) = 1.884, p > 0.05). The data

22

suggests that parent concussion diagnosis does not impact
knowledge scores.

Table 11. Parent Concussion History & Raw Score
Parent Dx
Raw Score
N
Std.
History*
Mean
Deviation
Don’t
17.0
3
15.716
Know
Yes
25.88
34
7.503
No
26.92
106
4.990
Total
26.46
143
6.091
* Dx - Diagnosis
Hypothesis 5: There will be a difference in knowledge
scores of parents if their student athlete has a history of
concussions. Table 12 shows the distribution of student
athletes who sustained concussions and the parents’ raw
score. The ANOVA test was not significant (F(2,140) =
1.142, p > 0.05) and it appears knowledge scores are not
impacted by student athlete diagnosis history as it relates
to the Concussion Information Sheet.

Table 12. Student Athlete Concussion History & Raw Score
Student
Raw Score
N
Std.
Athlete Dx
Mean
Deviation
History
Don’t Know
20.0
1
Yes
27.85
52
3.415
No
25.73
90
7.098
Total
26.46
143
6.091

23

Additional Findings

A number of descriptive findings were calculated that
relate directly to the responses associated with the
effectiveness of the Safety in Youth Sports Act and the
Concussion Information Sheet. The parents’ average
knowledge score of the Concussion Information Sheet was
26±6 out of 36 possible points (74%). Out of 143 surveys,
50 parents scored 29 points or higher, which means 35% of
parents scored higher than 80% on the Concussion
Information Sheet questions.
Question 10 of the survey asked, “Were you aware of
the recently passed Safety in Youth Sports Act and what it
mandates”? A total of 141 responses were included; 43.3% of
parents said “yes” (N=61), 28.4% said “no” (N=40), 24.1%
said “somewhat” (N=34), and 4.3% said “don’t know” (N=6).
This data is shown in Table 13.

24

Table 13. Awareness of Safety in Youth Sports Act
N
Valid
Percent
Don’t
6
4.3
Know
Somewhat
34
24.1
Yes
61
43.3
No
40
28.4
Total
141
100.0

Question 11 asked the parents to indicate if they
learned something new following review of the PIAA
Understanding of Risk of Concussion and Traumatic Brain
Injury form? A distribution of 141 responses are as
follows; 44.7% of parents said “yes” (N=63) they did learn
something new, 44.7% said “no” (N=63), and 10.6% said
“don’t know” (N=15). This data is shown in Table 14.
Table 14. Learned Something New
N
Valid
Percent
Don’t
15
10.6
Know
Yes
63
44.7
No
63
44.7
Total
141
100.0

Question 12 of the survey stated “Following review of the
PIAA Understanding of Risk of Concussion and Traumatic
Brain Injury Form, do you feel better about recognizing the
signs and symptoms associated with concussions and the
proper management steps”? There were a total of 141

25

responses that displayed 68.1% answered “yes” (N=96), 19.9%
answered “no” (N=28), and 12.1% answered “don’t know”
(N=17). This data is shown in Table 15.
Table 15. Feel Better About Recognition
N
Valid
Percent
Don’t
17
12.1
Know
Yes
96
68.1
No
28
19.9
Total
141
100.0

A total of 22 symptoms were included in the signs and
symptom identification section of the survey. Table 16
shows 13 signs or symptoms associated with concussions and
were directly from the Concussion Information Sheet, and
nine not associated with concussions or are traditionally
related to other physical injuries. The most common
symptoms that were identified correctly were headache,
dizziness, nausea, vomiting, and confusion. 100% of
participants identified these as correct responses.
Three of the most commonly identified symptoms that
are not associated with a concussion but parents identified
them to be associated were seizure, weakness of neck
musculature, and black eye. Respectively, only 6.8%, 9.1%,
and 28% of parents identified these symptoms to not be
associated with concussions.

26

Table 16. Sign & Symptom Identification
Symptom
Yes
No
Don’t Know
(N)
(N)
(N)

Identified
Correct
Responses
(%)
27.7
50.4
100.0
61.2
99.3

Nosebleed*
55
36
39
Coughing*
32
66
33
Headache
134
0
0
Chest Pain*
15
79
35
Double
134
0
1
Vision
Memory Loss
133
0
1
Black Eye*
62
37
33
Pressure in
126
1
5
Head
Clear nasal
45
41
45
leakage*
Dizziness
134
0
0
Nausea
134
0
0
Vomiting
134
0
0
Weak neck
89
12
31
musculature*
Difficulty
134
0
1
paying
attention
Confusion
135
0
0
Extreme
33
48
50
thirst*
Light
131
1
3
sensitivity
Noise
sensitivity
121
3
10
Shivering*
33
40
57
Mentally
132
0
2
foggy
Balance
133
0
2
problems
Seizure*
104
9
19
* Signs/Symptoms that are not associated with the
Concussion Information Sheet

99.3
28.0
95.5
31.3
100.0
100.0
100.0
9.1
99.3
100.0
36.6
97.0
90.3
30.8
98.5
98.5
6.8

27

There were two questions related to helmets and
equipment specifically preventing concussions. Question 32
stated, “Helmets prevent concussions”, and revealed 46.7%
of parents (N=64) stated this as “true”, 48.9% of parents
(N=67) stated “false”, and 4.4% (N=6) stated “don’t know”.
Question 34 specifically stated, “Properly fitted equipment
prevents athletes from sustaining concussions” and revealed
20.4% of parents (N=28) identified this as a “true”
statement, 74.5% of parents (N=102) stated this as “false”,
and 5.1% (N=7) stated “don’t know”.

28

DISCUSSION

The literature suggests that parents, athletes, and
coaches could all benefit from more education on the topic
of concussions.4 Gourley et al concluded in their survey
based study that additional education could be beneficial
to parents and youth athletes.4 Lack of knowledge about
concussion has been implicated as the main reason for
athletes not reporting concussions.14
The purpose of this research was to assess parents’
knowledge of the information given on the PIAA
Understanding of Risk of Concussion and Traumatic Brain
Injury form. It is important to evaluate this Concussion
Information Sheet since it could be the only tool the
parent utilizes to learn about the injury. This chapter is
divided into three subsections: Discussion of Results,
Conclusions, and Recommendations.

29

Discussion of Results

The current study found one significant hypothesis,
schools that have a certified athletic trainer on staff,
displayed higher knowledge scores by the parents. Although
this one-way ANOVA revealed athletic trainers have an
impact on knowledge scores, the distribution of responses
(132 yes; 2 no; 8 don’t know) for this specific question
should be considered before conclusions are made. In order
to make a proper conclusion about this hypothesis, more
schools without athletic trainers should be surveyed in
order to compare the knowledge scores. The four remaining
independent variables (completed education level, size of
school, parent concussion history, and student athlete
concussion history) showed no significance and suggest that
they do not affect the Concussion Information Sheet
knowledge scores.
Question 13 of the survey asked parents if they feel
concussion education and awareness has improved as a whole.
84.5% of parents (N=120) stated “yes” they do feel
education and awareness has improved, 14.1% stated “no”
(N=20), and 1.4% stated “don’t know” (N=2). It is unknown
if the improvement of concussion education and awareness is
a direct result of the Safety in Youth Sports Act.

30

Questions pertaining directly to the effectiveness of
the Concussion Information Sheet and the Safety in Youth
Sports Act revealed a number of findings. There were 43.3%
of parents who were aware of the legislation and 68% of
parents stated they felt better about recognizing
concussions. The question referring to learning something
new following review of the Concussion Information Sheet
revealed the same percentage for “yes” and “no” answers
(44.7%). The distributions of these findings are in tables
13-15.
The signs and symptoms portion of the survey revealed
positive findings for the number of correct symptoms
identified. The more traditionally recognized symptoms,
possibly due to media exposure, were all identified
correctly by all of the parents (headache, dizziness,
nausea, vomiting, and confusion). The three incorrect
symptoms that were identified the most by parents as
symptoms of a concussion were; seizure, weakness of neck
musculature, and black eye. Although some youth athletes
may experience these symptoms following a blow to the head,
neck, or face, they are typically not directly associated
with a concussion but could identify a more serious medical
emergency.

31

Reasoning behind the high number of participants
answering true to question 32 (Helmets prevent concussions:
True; 46.7%, False; 48.9%) is unknown but this finding
could provide recommendations for future educational tools.
The last question of the survey stated, “Properly fitted
equipment prevents athletes from sustaining concussions”.
Although the majority of parents selected the correct
response (False; 74.5%), 20.4% of the parents still believe
properly fitted equipment will prevent a concussion from
occurring.

Conclusions

Evaluating youth concussion legislation is important
to help determine if what the law is mandating is doing
what it intends to do. The Safety in Youth Sports Act
requires educational training for coaches, written
clearance by a physician, signing of the PIAA Concussion
Information Sheet, and also immediate removal from play if
a concussion is suspected. Previous studies4,15-17 revealed
recognition of signs and symptoms, management, and proper
return to play are all important aspects of awareness and
concussion knowledge. In some cases, signs and symptoms can
arise hours after a blow to the head or body; therefore, it

32

is imperative medical professionals and youth sport
organizations educate the parents of young athletes so they
are able to recognize concussions after the fact.
The findings of this survey based study revealed
completed education, size of a student athlete’s school,
personal history of concussion, and student athlete’s
history of concussion does not affect a parent’s knowledge
of the Concussion Information Sheet. If a student athlete’s
school had a certified athletic trainer, it appears the
parent’s knowledge score was higher and could reinforce the
importance of athletic trainers in the secondary school.
There were several additional findings that could open
the doors for future research and provide educators with
information on specific misunderstood aspects of
concussions. There has not been any research to support
helmets completely preventing concussions or the use of
properly fitted equipment and its impact on concussion
prevention. The findings of this survey revealed a high
number of parents who believe helmets and properly fitted
equipment prevent concussions from occurring. Reasoning
behind this is unknown and could identify a major
disconnect in the Concussion Information Sheet. It is
speculated that there is a misunderstanding taking place
from the wording of the Concussion Information Sheet in the

33

properly fitted equipment section. It is unknown if these
misunderstandings are direct results from the Concussion
Information Sheet, but they do offer possible insight into
future research.
Out of the 22 symptoms parents were instructed to
identify, there were three prevalent symptoms that were
selected as correct, when really they were incorrect.
Seizure, weakness of neck musculature, and black eye were
identified by parents as being symptoms associated with a
concussion. Reasoning behind these incorrect responses
could be due to the fact that parent’s concussion
experience may have involved these symptoms, so they
directly associate them with the injury. Seizures and
weakness of neck musculature may very well accompany a
concussion, but typically if these are taking place they
resemble a more serious brain or spinal cord injury. Being
hit in the eye socket with an object such as a ball will
usually result in swelling and ecchymosis (discoloration)
around the area, typically referred to as a “black eye”. If
the force of the object is great enough, it is possible a
concussion may be sustained.
Providing evidence for the effectiveness of the Safety
in Youth Sports Act and the Concussion Information Sheet
was given in questions 10-12 of the survey. This data

34

(Tables 13-15) helps make conclusions on the level of
awareness and effectiveness of the legislation. There was a
high number of parents who were not aware or only knew some
of what the legislation mandates. Several positive findings
were shown in whether or not they learned something new,
and if the parent felt better about recognizing
concussions. These three questions provide insight for
future improvements to the Concussion Information Sheet but
also show the importance of the Safety in Youth Sports Act
and the information provided to parents.
The Concussion Information Sheet knowledge score
displayed an average of 26±6 out of 36 possible points
(74%). Although some participants did not complete all of
the questions included in the score, this percentage shows
a high number of parents that may not be retaining the
information provided to them. Only 50 parents (35%) scored
higher than 80% on the Concussion Information Sheet
questions. This statistic identifies the need for future
improvements to the Concussion Information Sheet so that
parents are fully aware and knowledgeable of the injury.

35

Recommendations

This study yields findings that could be beneficial
for future research on the Safety in Youth Sports Act and
also, provides useful information that administrators for
the Pennsylvania Interscholastic Athletic Association could
use for improving future concussion educational tools. From
the results of the questions concerning equipment
preventing concussions it is obvious there is a
misunderstanding about the amount of protection a helmet
provides.
A section in the Concussion Information Sheet titled,
“How can students prevent concussions”, provides
information on properly fitted equipment and its protection
when it is used correctly. Although the section does not
mention that helmets prevent concussions, the statement
“for equipment to properly protect a student, it must be:”
could possibly be misleading causing perceptions that
equipment prevents injury. Although equipment may help
reduce injury, it cannot fully protect a student athlete
from suffering a concussion. Restructuring the equipment
section of the PIAA Concussion Information Sheet could
correct any misunderstood or misleading information.

36

Considering a total of 52.5% of parents were not aware
or had somewhat of an idea about the Safety in Youth Sports
Act identifies there is still a lack of awareness on the
recently passed legislation. This lack of awareness could
be due to the fact that the law is still very recent
(2012), information is not being effectively disseminated
to parents, and/or parents of youth athletes are just
unaware there is legislation in place to regulate education
and management of the injury.
Data in this research suggests that schools that
employ a certified athletic trainer have a greater impact
on parents’ knowledge of the Concussion Information Sheet.
With that said, a larger sample size of parents with
schools without athletic trainers should be surveyed in
order to draw more concrete conclusions on the effect.
Due to an average of 74% on the Concussion Information
Sheet questions, it would be useful to have the parents of
the PIAA complete a follow-up survey in the coming years.
If the knowledge scores were to improve, that information
would show a higher level of effectiveness of the Safety in
Youth Sports Act.

37

REFERENCES

1. Harmon KG, Drezner JA, Gammons M, et al. American medical
society for sports medicine position statement:
Concussion in sport. Br J Sports Med. 2013;47:15-26.
2. Lebrun CM, Mrazik M, Prasad AS, et al. Sport concussion
knowledge base, clinical practices and needs for
continuing medical education: A survey of family
physicians and cross-border comparison. Br J Sports Med.
2013;47:54-59.
3. Grady M. Concussion in the adolescent athlete. Curr Probl
Pediatr Adolesc Health Care. 2010;40:154-169.
4. Gourley MM, Valovich Mcleod TC, Curtis Bay R. Awareness
and recognition of concussion by youth athletes and their
parents. Athl Trng Sport Health Care. 2010;2(5):208-218.
5. McCrory P, Meeuwisse W, Aubry M, et al. Concensus
statement on concussion in sport: The 4th international
conference on concussion in sport held in Zurich,
November 2012. Br J Sports Med. 2013;47:250-258.
6. Livingston S. The neurophysiology behind concussion signs
and symptoms. Int J Athl Ther Trng. 2011;16(5):5-9.
7. Chertok G, Martin I. Psychological aspects of concussion
recovery. Int J Athl Ther Trng. 2011;18(3):7-9.
8. Wetjen N, Pichelmann M, Atkinson J. Second impact
syndrome: Concussion and second injury brain
complications. J Am Coll Surg. 2010;211(4):553-557.
9. Saunders R, Harbaugh R. The second impact in catastrophic
contact-sports head trauma. JAMA. 1984;252:538-539.
10. 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;14:13-17.
11. Shenouda C, Hendrickson P, Davenport K, Barber J, Bell
KR. The effects of concussion legislation one year laterwhat have we learned: A descriptive pilot survey of youth
soccer player associates. AM Acad Phys Med Rehabil.
2012;4:427-435.

38

12. Safety in youth sports act, HR 200, PA 2012.
13. Pennsylvania interscholastic athletic association. A
principals’ organization, principle-based. 2014.
14. Sawyer R, Hamdallah M, White D, Pruzan M, Mitchko J,
Huitric M. High school coaches’ assessments, intentions
to use, and use of a concussion prevention toolkit:
Centers for Disease Control and Prevention’s Heads Up:
Concussion in high school sports. Health promot Pract.
2008;1-10.
15. Valovich McLeod T, Schwartz C, Bay C. Sport-related
concussion misunderstandings among youth coaches. Clin J
Sport Med. 2007;(17):140-142.
16. Kaut K, DePompei R, Kerr J, Congeni J. Reports of head
injury and symptom knowledge among college athletes:
Implications for assessment and educational intervention.
Clin J Sport Med. 2003;(13)213-221.
17. Cusimano M, Canadian minor hockey participants’ knowledge
about concussion. Can J Neurol Sci. 2009;(36):315-320.

39

APPENDICES

40

Appendix A
Review of Literature

41

Literature Review

Concussion in sport has been a recurring topic over
the past decade in recreational, elite and professional
sports. It is estimated 1.6 to 3.8 million concussions
occur each year in the United States and approximately 50%
of those go unreported.1-3

There has been a lot of new

research examining different helmets in contact sports
along with rule changes directed at protecting the athlete
from possible head injury.
Along with new rules and equipment for safety
concerns, there are several nationally recognized
organizations that assist in providing information for
parents and coaches about concussions and what to do when
one occurs. Several of the articles in this literature
review highlight some of these organizations, including;
Center for Disease Control, American College of Sports
Medicine, National Athletic Trainers’ Association, American
Academy of Neurology and American Medical Society for
Sports Medicine. Also included are several nationally and
internationally recognized journals; International Journal
of Athletic Therapy and Training, British Journal of Sports
Medicine, International Journal of Sports Physical Therapy,

42

Journal of Family Practice, Journal of School nursing and
the Clinical Journal of Sports Medicine.
The purpose of this literature review is to first
examine what parents need to know about concussions so they
are properly prepared to care for their child without
assistance from a medical professional. This includes
recognizing signs and symptoms, understanding postconcussion treatment, and return to play protocols. This
literature review will also discuss the presence of
concussions in specific sports, the education and awareness
of concussions among parents and coaches, and also newly
formed laws enacted to protect young athletes from future
injury.

Concussion Background

Signs and Symptoms
Concussion is a brain injury and a complex
pathophysiological process affecting the brain, induced by
biomechanical forces.1,4 These biomechanical forces can be
caused by a blow to the head, face, neck, or somewhere else
on the body that distributes a force to the head. A change
in the rotational velocity and angular acceleration of the
brain is the result, which causes the brain injury.21 The

43

signs and symptoms following a concussion can be at the
onset, or several minutes to hours after the injury. Most
commonly, athletes report a headache as a post concussive
symptom along with dizziness 23% of the time in a post
concussive assessment.5-11 The most common types of these
post-traumatic headaches are tension headaches, migraine
headaches, combined migraine and tension headaches, and
cognitive fatigue headaches.5,12-14
Several other symptoms are summarized in the Consensus
Statement of the 4th International Conference on Concussion
in Sport held in Zurich, November 2012 by McCrory, et al.
These were classified into clinical domains: Symptoms
(headache, feeling in a fog, dizziness, lability), physical
signs (loss of consciousness, amnesia), behavioral changes
(irritability), cognitive impairment (slowed reaction
time), and sleep disturbance (insomnia). Symptoms included
in the article by Lear and Hoang15 Sport Concussion: A
return-to-play guide, was adapted from the Sport Concussion
Assessment Tool (SCAT2). These symptoms are as follows:
headache, pressure in head, neck pain, nausea or vomiting,
dizziness, blurred vision, balance problems, sensitivity to
light and/or noise, feeling slowed down, feeling like “in a
fog”, “don’t feel right”, difficulty concentrating,
difficulty remembering, fatigue, confusion, drowsiness,

44

trouble falling asleep, irritability, sadness, and
nervousness or anxiety.15 In the assessment of a
concussion, any of these symptoms or combination of these
symptoms may or may not be present and may arise minutes to
several hours after the initial injury.

Neurophysiology and Neuropsychology
In the following sections, other aspects of
concussions will be discussed along with management and
return to play protocols. When managing concussions it is
helpful to understand the physiology of brain function that
is causing the symptoms to occur. An animal model depicting
a concussion or mTBI has been developed and is termed the
Lateral Fluid Percussion brain injury model.3 This produces
injury to the brain using a device to drive fluid against
the intact dura of an exposed brain surface, which in turn
creates a small brain contusion and a small amount of
surrounding hemorrhage. A concussion injury can be looked at
as a two part process, the first being the initial injury
to the brain, secondly the inflammatory process that
accompanies any physical injury. This initial injury
creates ion disruption within the cell walls, which in turn
results in cellular death. As severely injured cells die,
they release cytokines that stimulates the inflammatory

45

process. The secondary injury is a result of these cytokines
being released and may explain why some concussion symptoms
do not arise until minutes or hours after injury. Knowledge
of concussion symptoms and the neurophysiologic process is
critical for the proper recognition of potentially lifethreatening traumatic brain injuries.16
There are some signs and symptoms of concussions not
always visible and may not appear to be a factor in the
treatment of an individual. Along with the
neurophysiological component there is the
neuropsychological component, which plays a big role in
recovery time and management. The concussed athlete may
experience a variety of psychological symptoms including
long-term effects such as depression, anxiety, psychosocial
problems, physical and cognitive disturbances, and chronic
traumatic encephalopathy.17 Certified Athletic Trainers play
a crucial role in this regard because they spend time with
the athletes on a daily basis. Athletes who have adverse
emotional responses to concussion symptoms may experience a
prolonged recovery that is associated with muscle tension,
anxiety, changes in heart rate, and sleep disturbances.

46

Second Impact Syndrome and Recurrent Concussions
Athletes who experience multiple brain injuries in a
short period of time (hours, days, weeks) may suffer
catastrophic or fatal reactions related to Second Impact
Syndrome.18,45 Second Impact Syndrome occurs when a concussed
athlete returns to sport and receives a second blow (may or
may not be as significant as the initial concussion) before
the original symptoms are resolved. The result is rapid and
profound brain swelling and can lead to severe and rapid
onset of symptoms, which in some cases can result in
death.18,45,46 Saunders and Harbaugh coined the term second
impact syndrome in there 1984 description of a 19 year old
college football player who suffered a head injury with
brief loss of consciousness, returned to play, reported a
headache, and on the 4th day collapsed, became unresponsive,
and died.19,20 Second Impact Syndrome solidifies the reasons
to recognize, properly manage, and treat concussed athletes
so they do not suffer from the possibly fatal consequences
of returning to competition to soon.
The importance of obtaining a detailed concussion
history before the start of athletic competition cannot be
stressed enough. Concussion or TBI has been identified as a
risk factor for chronic depression and a potential risk
factor for the occurrence of Alzheimer’s disease and

47

Parkinson’s syndrome.21-23 Recently this topic has come up in
the National Football League with retired players such as
Junior Seau and others who suffered from multiple
concussions over their NFL careers. A survey of over 2500
retired professional American football players found an
11.1% prevalence of clinical depression and, more notably,
an increased incidence of depression with increasing number
of concussions.21,24

Concussions in Adolescents

Knowing the signs and symptoms of a concussion and the
possible repercussions of mismanaging them is just the
first step in concussion awareness and treatment. The
following section examines literature focused on adolescent
concussions in sport and how to properly treat and safely
return them to play.

Management and Treatment
There is no gold standard for the diagnosis of
concussion or TBI but there are several resources medical
professionals can use.25 The study done by Yang et al,
examined hospitalizations for sport related concussions in
children aged 5 to 18 years old from 2000 to 2004. Out of

48

755 sport related concussions, 143 received principle
procedures (MRI, CT Scans) with 59.4% being CT scans and
10.5% being an MRI of the brain and brain stem.26 Brain
imaging should only be ordered in the presence of
progressive neurologic decline and or high-risk of injury
mechanism that could have caused a skull fracture or
intracranial bleed.27-29
One of the widely used concussion assessment tools is
the Sport Concussion Assessment Tool (SCAT2), which can be
used in the clinical and on the field settings to evaluate
and manage a concussion by a Certified Athletic Trainer or
other medical professional. This tool has shown unreliable
results in adolescents and therefore a pre-season baseline
assessment with comparative measures post-concussion should
also be used in the assessment and management of
concussions.27
Concussion management in the adolescent athlete should
be considered more conservative and focus on an individual
treatment plan. Adolescent brains are still maturing during
this early stage of life and therefore will take longer
than adult brains to heal from injury. It is important to
maintain symptom free status while gradually preceding
through a return-to-play protocol. Physical and cognitive
rest is required for the brain to heal, which can be

49

difficult for adolescent athletes. Cognitive rest involves
refraining from using all media devices including phones,
computers, video games, and TVs as well as being absent
from school activities such as homework.27,30 Physical rest
involves avoiding exercise of sports whether they are
recreational, organized, practice or competition. It is
also important to obtain day-to-day evaluations to ensure
recovery is taking place at an acceptable pace and to note
the increase or decrease of symptoms.

Return-to-Play
One of the most difficult aspects of managing a
concussion is determining when to allow the athlete to
return to competition. As previously stated, adolescent
athletes take longer to recover and should be managed
conservatively with returning to play. Child athletes
should remain symptom free before starting a medically
supervised stepwise exertion protocol.31 A recent study from
2012 examined 100 adolescent and 100 young adult athletes
who suffered a sport related concussion by using the
neurocognitive Immediate Post-Concussion assessment and
Cognitive Testing battery (ImPact).32 The study suggested
13-16 year old athletes take longer to return to their

50

neurocognitive and symptom baselines than 18-22 year old
athletes.32
Once an athlete is symptom free at rest they may begin
a return-to-play protocol supervised by a medical
professional. As previously stated, it is also important to
obtain day to day symptoms during the protocol period. The
most accepted protocol for return to play is a six step
sequence outlined in the Consensus statement on concussion
in sport: the 4th International Conference on Concussion in
Sport held in Zurich, November 2012.4 The stepwise
progression is as follows: no activity, light aerobic
activity (walking), sport specific activity, non-contact
training drills, full-contact practice, return to game. The
athlete should take 24 hours to proceed through each step
and must remain symptom free before moving onto the next
step.31 If symptoms reoccur after exertion the athlete
should follow up with their supervising medical
professional to determine when to move on to the next step.

Concussions in Several Contact Sports

Football
Football is a high contact physical sport and presents
medical professionals with a large variety of different

51

injuries. High school football players are the single
largest cohort of athletes playing tackle football, and
account for the majority of sport related concussion.33 Over
the past decade, football organizations at all levels have
been adjusting rules of the game in order to protect their
athletes. State laws have also been enacted to maintain
proper management and return to play of concussed
individuals. 44 states and Washington D.C. have passed
youth sport TBI laws since 2009 and the majority of these
laws focus on increasing coach’s and parents’ ability to
identify and manage TBIs and reduce the immediate risk of
multiple TBIs.43 One of the laws discussed in further
paragraphs is the Youth Sports Safety Act passed in
Pennsylvania in 2011.
An 11-year study performed from 1997 to 2008 examined
the incidence of concussion in 12 high school sports for
boys and girls. The data revealed a total of 2651
concussions and an incidence rate of .24 concussions per
1000 athletic exposures.34 Football accounted for 53.1% of
all concussions and had an incidence rate of .60
concussions per 1000 athletic exposures. Over the 11 years
there was a concussion rate increase of 4.2 fold, a 15.5%
increase for all sports.34 This rate of increase could
possibly be due to actual increased occurrence or an

52

increase of awareness, which has in turn made detection and
management more evident. An article published by the
Journal of School Health made several recommendations on
the topic of concussions in football.33 Johnson recommended
eliminating tackling from school football for youth under
the age of 16 years old. It was also recommended shortening
the competitive season, limiting on-field time during
games, and adopting “hit counts” similar to pitch counts in
little league baseball.33

Lacrosse
Lacrosse is another sport that has a significant
amount of concussions at all levels but is not publicized
as much as football. The 11-year high school study
mentioned above also included the incidence of concussions
in boy’s and girl’s lacrosse. The total number of
concussions in lacrosse was 358 with a .50 rate per 1000
athletic exposures.34 The total for boys was 244 concussions
with a .30 rate per 1000 athletic exposures and girls was
114 with a .20 rate per 1000 athletic exposures. Boys had a
17% mean annual increase and girls had a 14% mean annual
increase during the 11 year study. This statistical
evidence shows a significant amount of concussions in

53

lacrosse and also displays noteworthy mean annual increases
in both boys and girls.
A study performed in 2002 published by the Journal of
Athletic Training examined the effects of repetitive impact
forces on lacrosse helmets and set out to increase
awareness of helmet safety standards.35 The study took two
traditional helmets and two contemporary helmets and
measured the Gadd Severity Index (GSI) after repetitive
drops on a rubber modular elastomer programmer. The
findings of the study indicated all the helmets had
decreased capacity to dissipate forces after repetitive
blows due to increased GSI scores.35

Soccer
Along with lacrosse, soccer has a noticeable number of
concussions in both boys and girls. One of the 12 sports of
the study mentioned above examining incidence rates of
concussions in high school athletics was boys and girls
soccer.34 Girls’ soccer had the most concussions of the
girls’ sports (195) and the second highest incidence rate
of all 12 sports (.35). The study also revealed in similar
boys and girls sports (baseball/softball, basketball,
soccer), girls had roughly twice the concussion risk of
boys.34

54

A study published in 2006 by the British Journal of
Sports Medicine examined the effect of protective headgear
on head injuries and concussions in adolescent soccer.36 The
headgear used in the study was described as “head gear with
no chin strap and protection around the front, sides, and
back of head”.36 There were 278 completed surveys with 216
athletes who did not wear headgear and 52 athletes who did
wear headgear. The results of the study showed 26.9% of
athletes who wore headgear suffered a concussion and 52.8%
of athletes who did not wear headgear suffered a
concussion.36 Analysis of the data displayed in this
adolescent population, female athletes and athletes who did
not wear headgear were more likely to suffer a concussion,
which supports previous research indicating female athletes
are more susceptible to concussions in soccer.36-38
Unlike football and lacrosse, little can be done to
prevent concussions occurring in soccer, regardless of the
level of competition. Rule changes have effected all three
of these sports over the past several years and usually
only occur when there is a clear-cut mechanism implicated
in a particular sport.30 An example of this in soccer is
where studies have shown upper limb to head contact in
heading accounted for approximately 50% of concussions.36 As
stated in previous paragraphs, a concussion is a

55

traumatically induced disturbance of brain function caused
by biomechanical forces on the head, neck, or body. This
disturbance of brain function is due to linear and/or
rotational forces transmitted to the brain.1 When these
forces occur the brain moves within the skull which causes
cellular and metabolic changes creating the disturbance in
brain function. There is currently no evidence-based
equipment that can prevent concussions or the movement of
the brain inside the skull. The only way to fully prevent
concussions or TBIs is to eliminate the biomechanical
forces that occur to the brain, which can be a difficult
task in some cases.

Education and Awareness

Concussion Knowledge Surveys
There have been several studies performed over the
past 5 years dealing with the knowledge of concussion
awareness on high school athletes, parents, and coaches. A
survey study by Esquivel et al wanted to examine if there
are differences in concussion management and awareness
among boys’ football, boys’ ice hockey, and boys’ and
girls’ soccer.39 The survey was intended to be completed by
athletic directors, athletic trainers, and coaches. A total

56

of 235 responses were received and showed concussion
awareness education was given to football players 97% of
the time, hockey players 65% of the time, boys soccer 57%
of the time, and girls soccer 47% of the time.39 The survey
also asked if the school had a written policy in place to
manage concussions and the results showed 50% of athletic
directors, 53% of ATCs, and 62% of coaches said yes.39
Esquivel et al concluded concussion awareness is promoted
well in football, but should be expanded in soccer and
hockey.
Assessing the knowledge of parents, athletes, and
coaches on concussions is an important piece to consider
when examining concussion management and return to play.
The assessment can identify weak areas in education and
assist in improving the concussion education programs.
Gourley et al investigated the knowledge of youth athletes
and their parents regarding concussion and their ability to
recognize it and properly treat it.40 A survey was
administered to athletes and their parents and consisted of
73 athletes (aged 10-14) and 100 parents. Results displayed
no differences among athletes and parents on correct
responses in the symptom recognition portion of the survey,
with mean scores of 9.19 and 9.23 (of 16).40 The only area
where differences were noted was the second scenario

57

question where 22% of athletes and 43% of parents correctly
responded to “an athlete should not return to play if he or
she was awake with no loss of memory, asymptomatic at rest,
and only had a headache with activity”.40 It was also noted
parents with previous medical training (CPR, First Aid)
scored significantly better on the symptom recognition
portion of the survey.
Two other studies focused strictly on coaches’
knowledge of concussions including recognition, management,
and prevention and also evaluated the use of the Center for
Disease Control’s “Heads Up: Concussion in Youth Sports”
initiative. The first was conducted by O’Donoghue et al and
involved a cross-sectional survey of 126 high school
coaches.41 The three sections of the survey were
recognition, management, and prevention with eight possible
points and 24 total points.41 Mean scores consisted of
recognition, 7.39; management, 6.33; and prevention, 6.53
with a total of 20.27.41 Coaches overall concussion
knowledge was 84%, the highest being the recognition
section with 92% and the lowest being the management
section with 79%.41
Covassin et al examined the usefulness of the CDCs
“Heads Up: Concussion in Youth Sport” initiative by
surveying 340 youth sport coaches.42 The CDC “Heads Up”

58

material can be obtained online for free and involves a
fact sheet for coaches, parents, and athletes, a clipboard
information sheet, a magnet and a poster. The results of
the survey found 77% of coaches reported being better able
to identify athletes who may have a concussion, along with
50% stating they learned something new about concussions
after reviewing the material.42 Coaches reported the fact
sheet for coaches (65.7%) and the magnet (63.8%) were the
most useful materials of the CDCs “Heads Up: Concussion in
Youth Sports”.42

Legislative Research
A recent study published in 2013 was performed by
Harvey H. who investigated state laws involving youth sport
TBIs and also included a data set of the current laws.43
Since the beginning of 2009, forty-four U.S. states and
Washington DC, passed legislation designed to reduce the
overall impact of TBIs. The scope of these laws include 24hour mandatory removal from play, requiring assessment from
a medical professional before return to play, and coach
training in concussion management and recognition.43 Instead
of focusing on primary prevention, the majority of the laws
passed focus on parent and coach awareness and their
ability to recognize symptoms of a concussion.

59

Another survey-based study examining the effectiveness
of the Lystedt Law in Washington State was performed by
Shenouda et al. The Lystedt Law was signed in May 2009 and
requires coaches, parents, and youth athletes to be
educated about concussions and sign a “concussion injury
information sheet”.44 Shenouda et al wanted to determine if
adults associated with youth soccer programs in Washington
State were properly educated on recognition, management,
and prevention following the Lystedt Law. A total of 391
adults responded to the survey and the results displayed
96% knew concussions were a TBI, 93% identified concussions
to be serious, and 85% were aware of the newly formed
Lystedt Law.44 Shenouda et al concluded the data suggests
knowledge of concussions to be high with Washington State
adult associates of youth soccer leagues but some gaps
regarding prevention may still be present.
The Safety in Youth Sports Act also known as the
Pennsylvania Senate Bill 200 Act 101 was passed in 2011 and
applies to all interscholastic athletics. This legislation
requires immediate removal from play if an athlete is
exhibiting signs or symptoms of a concussion, and also
states that the athlete must be cleared by a licensed
medical professional before returning play. Coaches must
complete an annual concussion education course before the

60

season of their respective sport begins. A student
participating in an athletic activity and the student’s
parent or guardian shall each school year, sign and return
to the school acknowledgement of receipt and review of the
Understanding of Risk of Concussion and Traumatic Brain
Injury form.47 Also, known as the Concussion Information
Sheet, it covers what a concussion is, the signs and
symptoms of a concussion, what athletes should do if they
suspect a concussion, and how athletes can prevent
themselves from further injury following a concussion.
The Safety in Youth Sports Act has not been followed
up on since its passing in 2011. Research on the
effectiveness of the Concussion Information Sheet on
parents’ and athletes’ knowledge of concussion is lacking.
A disconnect is present within this newly founded law
because there are no measures to determine the level of
knowledge parents obtain from signing the Concussion
Information Sheet. The Safety in Youth Sports Act requires
coaches to complete a concussion education course such as
the Center for Disease Control’s “Heads Up” Concussion in
Youth Sports training for coaches. With this specific
course, coaches must obtain an 80% or higher on the final
quiz in order to obtain their certificate of completion. In
regards to the parents’ knowledge following review/signing

61

of the Concussion Information Sheet, there is currently no
threshold they must meet prior to their child competing in
athletics. It has been shown in previous studies40,48-50 that
recognition of concussion signs and symptoms, concussion
management, and return-to-play guidelines are all important
aspects of concussion awareness and knowledge. This study
will examine the Concussion Information Sheet to help
determine whether the Safety in Youth Sports Act is doing
what it intended to do.

Conclusion

Concussions in sport have been increasing over the
years which could be due to better medical coverage and
public awareness or the incidence rates are just increasing
themselves. The importance of parent and coach education on
concussions is stressed in the literature and supports the
need for mandated legislative laws. This literature review
covered a number of different topics to stress the
importance and seriousness of concussions. Regardless of
the severity, all concussions need to be taken seriously
and parents and coaches need to be able to accurately
recognize, manage, and return a concussed athlete as safely
as possible. Future research could consider more evidence

62

based work on adolescent athletes and the reliability and
validity for concussion assessment tools specific to this
age group.

63

Appendix B
The Problem

64

Statement of the Problem

The problem associated with this study is that the
recently passed Safety in Youth Sports Act does not include
any follow-up measures to test whether it is effective or
not. The focus of this study examines the Concussion
Information Sheet which must be signed by the athlete and
parent/guardian prior to every athletic year. Over the past
decade there has been increased discussion concerning
concussion awareness, prevention, and management at all
levels of athletics. It is important to focus on adolescent
athletes and their parents because once the concussed
athlete leaves the medical professionals care, if any was
available, it will be the parent’s responsibility to
recognize various signs, symptoms and to determine whether
further medical intervention is required.

Definition of Terms
1. Concussion – Type of traumatic brain injury involving
complex pathophysiological processes induced by
biomechanical forces affecting the brain.1,4
2. Content Validity – Depends on the extent to which an
empirical measurement reflects a specific domain of
content.51

65

3. Construct Validity – Depends on the extent to which a
particular measure relates to other measures
consistent with theoretically derived hypotheses
concerning the concepts that are being measured.51

Basic Assumptions
The following are basic assumptions of this study:
1. The participants will be honest when they complete the
demographics portion of the survey.
2. The participants will complete the survey to the best
of their ability.
3. The athletic directors who are members of the
Pennsylvania State Athletic Directors Association will
distribute the survey link appropriately to their
schools’ parents.
4. The intended recipient will complete the survey.

Limitations of the Study
The following are possible limitations of the study:
1. Not being able to distribute cover letter and survey
link directly to parents in the PIAA.

66

2. The above limitation caused the inability to have an
accurate rate of return; therefore, it was unknown how
many surveys were sent to the parents.
3. Some participants may not have computer or online
access.
4. Unaware if athletic directors at schools have access
to all of the parent’s current emails.
5. Limited amount of time for the survey window to be
open to the parents.

Statement of Significance
The findings of this study are significant because it
is important for health organizations and medical
professionals to make sure they are educating parents of
youth athletes about the seriousness of sport related
concussion. Regardless of what sport is being played the
athlete’s parents should be able to recognize a concussion
and know when to seek further medical attention. Since it
has been demonstrated by several studies that adolescent
brains are more susceptible to concussions,1,2 it is
important the athlete’s parents are prepared to care for
and manage them correctly.
This study examines the effectiveness of the
Concussion Information Sheet put in place by the

67

Pennsylvania Senate Bill 200 Act 101, which requires the
parents and their athletes to review and sign the
information sheet before every school year. Gathering this
information will tell us whether or not more effort needs
to go out for educating and spreading awareness about sport
related concussions and also help determine the
effectiveness of the recently passed legislation. If there
are certain domains of concussions (symptoms, treatment,
and return-to-play) that have a trend of being
misunderstood, medical professionals will be able to better
understand what information is being relayed correctly and
which needs to be revised. It is important to make sure all
youth parents are fully knowledgeable and can identify,
manage, and treat sport related concussions when not in the
presents of a medical professional.

68

Appendix C
Additional Methods

69

Appendix C1
Understanding of Risk of Concussion and Traumatic Brain
Injury

70

71

Appendix C2
Institutional Review Board

72

73

Appendix C3
Concussion Information Sheet Survey

74

Concussion Information Sheet Survey
(SurveyMonkey format)

* Required to answer, disqualification if younger than 18

* Required to answer, disqualified if younger than 18

75

* Required to answer, disqualified if child does not
participate in PIAA athletics

76

* Question 6 (drop-down menu): displays education levels
grade school through graduate school
* Question 7 (drop-down menu): displays a list a various
occupation categories

77

78

* Questions 14 and 19 were drop-down menus with number
selections for age and years

79

80

* Each sign and symptom had its own drop-down menu with
Yes/No/Don’t Know selections

81

82

* If participants were disqualified they were sent to this
page

83

Appendix C4
Validity Questionnaire for Panel of Experts

84

Validity Questionnaire
(Questions answered by panel of experts)

1. Does the survey show adequate construct validity in
relation to the concussion information sheet?

2. Does the survey show adequate content validity in
relation to the concussion information sheet?

3. Are there questions too broad or misleading (from a
parents’ perspective)?

4. Are there any grammatical or phrasing issues?

5. Any other comments?

85

Appendix C5
Cover Letter to Athletic Directors
& Parents

86

Date: 3/17/14
Dear Athletic Director:
My name is Trevor O’Brien and I am currently a student
in the Graduate Athletic Training Education Program at
California University of Pennsylvania. I am performing a
survey-based research study to evaluate the effectiveness
of the concussion information sheet included in the PIAA
Comprehensive Initial Pre-Participation packet. The Safety
in Youth Sports Act, effective in 2012, requires all
parents and athletes to review and sign the concussion
information sheet prior to each school year. I want to
determine the knowledge level of parents by having them
complete a survey, which directly reflects the material on
the concussion information sheet. Gathering this
information is significant because it will help determine
whether or not the concussion information sheet is doing
what it intends to do and also determine the effectiveness
of the Safety in Youth Sports Act.
The survey will be completed on SurveyMonkey.com and
the link to access the survey is attached on the same email
this cover letter was attached to. You are being asked to
distribute the survey link to all parents of student
athletes associated within your school district. You do not
need to complete the survey yourself, it is strictly for
parents of student athletes. I do ask that you distribute
the survey at your earliest convenience as it will only be
available to the parents for two weeks following you
receiving this letter. Your participation is voluntary and
you do have the right to choose not to distribute the
survey. Your participation or non-participation will have
no benefit or penalty.
All survey responses are anonymous and will be kept
confidential. Completed surveys will not have any

87

information that will allow you or the parents to be
identified. Electronic data will be stored in passwordprotected files on California University of Pennsylvania’s
servers. Minimal risk is posed by participating and
distributing the survey to the parents in your school
district. I ask that you please consider the possible
benefits of participating and collecting this data because
it will directly reflect how much information parents
retain every year from the concussion information sheet. If
you have any questions regarding this project, please feel
free to contact the primary researcher, Trevor O’Brien,
LAT, ATC at obr4699@calu.edu. You may also contact the
thesis chair supervising the research, Dr. Michael Meyer,
LAT, ATC at meyer_m@calu.edu.
Lastly, I will share the results of this research with the
PIAA and any school requesting the results.
Thank you for taking the time to take part in this
research. I greatly appreciate your time, thought, and
effort you have put into your participation.
Sincerely,
Trevor O'Brien, LAT, ATC
Primary Researcher
California University of Pennsylvania
Graduate Athletic Training Education Program
250 University Ave
California, PA 15419
Obr4699@calu.edu

88

Dear parent or guardian:
My name is Trevor O’Brien and I am currently a student
in the Graduate Athletic Training Education Program at
California University of Pennsylvania. I am performing a
survey-based research study to evaluate the effectiveness
of the concussion information sheet included in the PIAA
Comprehensive Initial Pre-Participation packet. The Safety
in Youth Sports Act, effective in 2012, requires all
parents and athletes to review and sign the concussion
information sheet prior to each school year. I want to
determine the knowledge level of parents by having them
complete a survey which directly reflects the material on
the concussion information sheet. Gathering this
information is significant because it will help determine
whether or not the concussion information sheet is doing
what it intends to do and also determine the effectiveness
of the Safety in Youth Sports Act.
You are being asked to participate because you have a
son(s) or daughter(s) participating in athletics under the
PIAA. However, your participation is voluntary and you do
have the right to decline participating in this survey. You
also have the right to discontinue participating at any
time during the survey completion process, at which time
your data will be discarded. Your participation or nonparticipation will have no benefit or penalty. This study
was approved by the California University of Pennsylvania
Institutional Review Board. The effective date of the
approval is 03/14/2014 and expiration date is 03/14/2015.
All survey responses are anonymous and will be kept
confidential; by completing this survey, you are providing
informed consent to use the data collected upon return of
the survey. Completed surveys will not have any information
that identifies you, your child, or associated school

89

district. Electronic data will be stored in passwordprotected files on California University of Pennsylvania’s
servers. 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 10 minutes to complete. I also ask you
consider the benefits of gathering this data as it will
identify strengths and weaknesses of the recently passed
legislation focused on protecting your son(s) or
daughter(s) from head injury. If you have any questions
regarding this project, please feel free to contact the
primary researcher, Trevor O’Brien, LAT, ATC at
obr4699@calu.edu. You may also contact the thesis chair
supervising the research, Dr. Michael Meyer, LAT, ATC at
meyer_m@calu.edu.
Thank you for taking the time to take part in this
research. I greatly appreciate your time, thought, and
effort you have put into completion of the survey.
Sincerely,
Trevor O'Brien, LAT, ATC
Primary Researcher
California University of Pennsylvania
Graduate Athletic Training Education Program
250 University Ave
California, PA 15419
Obr4699@calu.edu

90

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ABSTRACT
Concussion Knowledge among Youth Parents in the
Commonwealth of Pennsylvania: A survey based on the Safety
in Youth Sports Act
O’Brien TB, Meyer M, West T, Bishop V: The School of
Graduate Studies and Research, California University of
Pennsylvania; California, PA.
Context: In July of 2012, the Commonwealth of Pennsylvania
deemed the Safety in Youth Sports Act effective concussion
legislation. The law establishes standards for
interscholastic athletics; immediate removal from play for
anyone suspected of having a concussion, written clearance
by a licensed medical professional before returning to
play, concussion training courses for coaches prior to
every season, and signing of a concussion information sheet
by the parent and student athlete prior to every school
year. Objective: This study examines the knowledge of the
Concussion Information Sheet by parents who are associated
with the Pennsylvania Interscholastic Athletic Association
(PIAA). Design: This is a descriptive research design
utilizing a survey which directly reflects the information
on the PIAA Concussion Information Sheet. Participants: The
survey was sent to parents/guardians who have student
athletes competing in athletic events associated with the
PIAA. Interventions: An original survey was developed on
SurveyMonkey.com and sent via email to the parents. Main
Outcome Measures: After surveys were submitted, each parent
received an overall knowledge score that was used to test
the hypotheses and to draw further descriptive conclusions
on the data. Results: A total of 143 surveys were included
in the study (92 females, 48 males). The average knowledge
score by the parents was 26 out of 36 (74%). Schools that
employ a Certified Athletic Trainer will have an impact on
knowledge scores came back as significance. 43.3% of
parents stated they were aware of the recently passed
legislation. 44.7% of parents revealed they learned
something new following review of the information sheet.
68.1% of parents felt better about concussion recognition
following review of the information sheet. 46.7% of parents
stated that helmets prevent concussions and 20.4% stated
properly fitted equipment will prevent concussions.
Conclusion: Medical professionals and youth sport
organizations need to make sure they are providing proper
educational tools for parents regarding concussions in

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youth sports. Currently, there is no evidence to suggest
various demographic information effects knowledge of the
Concussion Information Sheet. Further research needs to
look more into the perceptions of parents on equipment and
concussions, along with improving awareness and knowledge
of the Safety in Youth Sports Act and what is mandated
under the legislation.