### Abstract

While the underreporting of concussions to high school football players has been previously documented through an investigation of the general understanding of football players, no studies to date have looked at high school football coaches’ general understanding of concussion. This study was conducted in 2006 with a dual purpose of examining the Idaho high school football coaches’ general understanding of concussion and determining whether or not those coaches were consistent with experts’ recommendations in concussion management, including the determination of the appropriate time for return to play. Questionnaires were sent to all Idaho high school head football coaches (n=128) of which 60% (n=77) responded. Data showed the consistency, or lack thereof, of concussion management and return to play, relative to published expert guidelines. Upon analysis it was clear that these coaches’ practices were not consistent with expert recommendations regarding identifying and managing concussion. Many coaches were unfamiliar with the signs and symptoms of concussion, and were especially naïve when it came to identifying instances of mild concussion, including “bell ringers” and “dings”. There was also a lack of awareness about objective tools related to return-to-play decision making. Coaches who had access to athletic trainers managed concussion more consistently. Across all levels, but especially in smaller schools, there was a lack of concussion education afforded to coaches.

**Keywords:** concussion, coaches, high school, football, education

### Introduction

An estimated 300,000 sport-related concussions occur annually in the United States, with high school football players suffering more than 64,000 of those injuries (4, 12, 29). These are the known cases. Thousands more are believed to go unreported (5,16, 29). A concussion is defined as, “any transient neurological dysfunction resulting from a biomechanical force that may of may not result in a loss of consciousness” (8, p. 228). Unlike a cut, a scrape, or a broken leg, concussive injuries are rarely visually obvious. What makes concussive injuries even more complicated is the fact that concussion is a functional injury, not a structural one, meaning it will affect neurocognitive performance but not necessarily show up on MRI or CT scans (5,6,31). This could contribute to the lack of concussion diagnosis or to the belief that concussion does not necessitate conservative treatment if structural damage is not found. In 1990, Dr. M. Goldstein (9) referred to concussion as “a silent epidemic” (p. 327). Unfortunately, nearly two decades later, Goldstein’s warning still sends shockwaves, as young athletes die from sport-induced concussions (1,13,25). Leading experts agree that high school athletes have a significantly greater risk of sustaining a concussion, and that those concussions take longer to heal when compared with concussions sustained by college-aged athletes (6,7). There are many potential reasons for this, but most researchers agree that the younger brain is more vulnerable because it is not fully developed (11,17). Furthermore, many concussions sustained by younger athletes go unreported because youth sport coaches, leaders, parents and even athletes themselves do not fully understand what concussion is or that it has occurred (6,16). Experts agree, even so-called “bell ringers” and “dings” require medical attention and should be considered concussive injuries (17,31). When such momentary states of disorientation or dizziness are ignored, an additional threat is posed in the form of Second Impact Syndrome, or SIS (1,13,22). SIS may occur when an athlete sustains a second concussion before the symptoms of the first have healed (1). Though rare, SIS is characterized by rapid swelling of the brain and may be fatal (2). SIS is most often associated with adolescent athletes, perhaps because of the sensitivity of their developing brains, and because the seriousness of the first concussion is often overlooked (1,5,13,22,28).

While the national spotlight illuminates instances of deaths that occur from sport-related concussion, there still remains the need to educate sport leaders on ways to protect the athletes who compete (21). The Centers for Disease Control and Prevention (3) offer a free toolkit, Heads Up: Concussion in High School Sports that is available to coaches at no charge. In addition, the National Athletic Trainers’ Association (NATA) and its Appropriate Medical Care for Secondary School-Aged Athletes Task Force (AMCSSAA) have made several recommendations (11). Among them are that every high school in the United States develop and implement a comprehensive athletic health care administrative system. Athletic trainers and physicians are critical components of that system (11,16).

Recognizing a lack of athletic trainers in Idaho’s secondary school setting and especially in the rural school environment, a study was conducted in 2006 with the dual purpose of examining the Idaho high school football coaches’ general understanding of concussion, and determining whether or not those coaches were consistent with experts’ recommendations when it came to managing concussion and determining the appropriate time for return to play following concussion. The findings make clearer the need for proper concussion management in high schools, including the need for athletic trainers and continuing education for coaches. Understanding the characteristics of concussion and recognizing the unavailability of athletic trainers, the following research questions guided this investigation:

1. Who was the person most often called upon to identify and manage concussive injury in Idaho’s high school football programs?
2. What is the Idaho high school football coaches’ general understanding of current research on concussion characteristics, evaluation and management?
3. Relative to published expert recommendations, how consistently did Idaho high school football coaches determine when it was safe to return concussed athletes to play?
4. What, if any, continuing education opportunities have been made available to Idaho high school football coaches in the area of concussion management?

### Methods

#### Participants

The participants consisted of 128 Idaho high schools fielding a high school football program. All head football coaches were invited to participate in the study (N=128) via postcards and e-mails, with contact information obtained through the directory of the Idaho High School Activities Association (IHSAA).

#### Instrumentation

This study involved the use of two instruments. The primary instrument was a questionnaire entitled *Profiles and Perceptions of Idaho High School Football Coaches*. This instrument was developed by the researchers to address the research questions, and employed a forced choice response format, supplemented by two open-ended questions. Once drafted, the questionnaire was subjected to expert review with two of the nation’s leading experts on concussion research and six athletic trainers from the Idaho Athletic Trainers’ Association.

The secondary instrument was *The Concussion Management and Return to Play Protocol*. This instrument employed a semi-structure interview protocol and focused on research questions two and three. Like the questionnaire, it was subjected to expert review as described above. The interview protocol was engaged in person with a small, purposive sample of high school football coaches (n=10). The interview questions were phrased to solicit responses that explained the coaches’ behaviors when it came to managing concussion and determining when it was safe to return an athlete to play.

#### Procedures

Institutional review board approval was obtained from Idaho State University before the study began. In mid-September of 2005, all Idaho head high school football coaches were invited to participate via a mailed postcard. The postcard summarized the study purpose and alerted the coaches that a survey packet would arrive the following week. At the same time, Idaho high school principals and athletic directors were informed about the study via an e-mail blast. Administrators were asked to encourage their coaches to participate. The following week the survey packets were mailed. The packets included an introductory letter, a copy of the primary instrument, and a postage-paid, self-addressed return envelope. Coaches were instructed to complete the questionnaire within a two-week time period. The following week, an email reminder was sent to both the coaches and athletic directors. Informed consent was implied upon completion and return of the questionnaire.

Interviews were conducted approximately 6 weeks after the return of the questionnaires. This time frame was chosen because it coincided with the state high school football playoffs and there was good accessibility to a purposive sample of coaches. The interviews were audiotaped and lasted between 10 to 45 minutes. Recorded interviews were transcribed verbatim and interviewees were sent the transcripts with a request to check for response accuracy. Because of convenience, electronic mail transmission was the preferred method for these communications. Coaches were encouraged to make necessary corrections and/or add additional comments. To ensure confidentiality, final verbatim transcripts were coded, and referenced in the study by those codes.

#### Data Analysis

For the primary instrument, data were analyzed using basic descriptive statistics. The data were also stratified according to athletic classification level (i.e., school size). Narrative data from the two open-ended questions, “In the space below, please describe any other signs or symptoms that you would expect to be a sign or symptom of concussion that are not listed above” and “Please use the space provided below to make comments/suggestions that could benefit you as a coach in recognizing the signs and symptoms of head injuries in sports” were reviewed and read noting common themes.

As Yin (33) pointed out, it is necessary to go beyond the simple collection of descriptive data and begin the complex procedure of analyzing behavioral characteristics. Therefore, it was deemed important to also consider the behaviors that guided the coaches’ decision-making processes. When reviewing the interview transcripts, processes of open and axial coding were used to help with pattern analysis (27). Open coding was the first step toward distinguishing “properties” and “dimensions” in the data (27, p. 102). Themes and subthemes emerged that helped to explain the coaches’ patterns of behavior. Special attention was directed to repeated words and phrases, and to the chronological behaviors of the coaches. We first identified these themes and subthemes and later their presence in the data was confirmed by a data analysis focus group consisting of athletic trainers from the Idaho Athletic Trainers’ Association. Focus group members were instructed to separate narrative data into their own major themes and subthemes. The focus group’s thematic analyses were then compared to the thematic analysis derived by the researchers. Finally, through discussion between the researchers and focus group members, the agreed-upon thematic constructs were narrowed and confirmed (see Table 1).

### Results

Study findings are reported first regarding respondent/interviewee demographics, then by questionnaire areas of inquiry. Specifically these areas of inquiry include: person(s) responsible for concussion identification and management, coaches’ understanding of concussion identification and management, return to play decision-making, coaches’ continuing education relative to concussion identification and management, and findings reviewed relative to school size.

#### Demographics

Of the 128 coaches invited to participate in the study, 77 responded, resulting in a 60.1% response rate. The responses represented all five Idaho high school athletic classification levels. All participating coaches confirmed they were the head varsity football coach at their school. Descriptive data related to participant demographics appear in Table 2. Of the responding coaches, 93.3% (n=70) stated they had taken a basic or advanced first aid course through the American Red Cross (ARC) or the American Heart Association (AHA), and 94.7% (n=71) stated they had taken a CPR course through one of the same organizations. Nearly 88% of the coaches (n=65) also mentioned they had received formal training in sports injury prevention at some time in their past. While 89% (n=66) of coaches could identify formalized educational training in sport-specific issues (such as tackling), only 42% (n=31) stated they had also received formal training in football equipment fitting (see Table 2).

#### Person(s) Responsible for Concussion Identification and Management

To better understand who identifies and manages concussion in Idaho high school football programs, the questionnaire asked the coaches to clarify the person(s) primarily responsible for evaluating sports related head injuries including concussion. Only 35.9% (n=23) acknowledged having an athletic trainer at their disposal regularly for practices and games. Coaches were asked, “When an athlete on your team sustains a head injury or suspected concussion, what is the title of the person who is most often called upon to evaluate the injury?” Understanding that some teams might have medical personnel on hand for game settings but not for practices, coaches were asked to clarify any differences that might exist between practice and game situations. Figure 1 depicts the summary of the coaches’ responses, and reveals the distribution of responsibility when it comes to evaluation of concussion (see Figure 1).

To better understand return to play practices, coaches were also asked, “When an athlete on your team sustains a head injury or suspected concussion, what is the title of the person who is most often called upon to determine when it is safe to return the athlete to play?” Again, responses were specific to practice and game situations. Figure 2 displays these responses, and shows the distribution of responsibility when it comes to determining return to play (see Figure 2).

#### Coaches’ General Understanding of Concussion Identification and Management

Despite the fact that an overwhelming majority of coaches had previously taken first aid or sports injury management courses, most Idaho high school football coaches felt they were unprepared to manage concussion inherent in football. 76.7% (n=56) of participants stated they did not feel they had been adequately trained in this area. Participants were also asked whether or not the risk of concussion in the sport of football concerned them. Overwhelmingly, 94.2% (n=65) of coaches said the risk of concussion in football did concern them.

Coaches acknowledged their job duties extend beyond schematics. 86.3% (n=63) of coaches felt they had a responsibility to be able to recognize the signs and symptoms of concussion and to know how to tell when it is safe to return an athlete to play. However, when participants were asked to identify what they felt those signs and symptoms of concussion were given a list, there seemed to be some confusion. While common signs and symptoms such as headache and disorientation were widely recognized, the majority of coaches did not understand that less-common symptoms, such as difficulty breathing and insomnia, are indicative of concussion, as well. Only 32% (n=24) of participants felt difficulty breathing could be associated with concussion, and 29% (n=22) understood insomnia to be connected to concussion. Other notable signs and symptoms of concussion were also mistaken, including sensitivity to noise (47%, n=35) and sensitivity to light (69%, n=52). Table 3 displays coaches’ responses when asked to identify whether or not a certain sign or symptom could be indicative of concussion. Experts have agreed that all of these signs and symptoms are consistent with concussion (11,17). It was important to note that 97.3% (n=73) of the participants understood that a concussion is not always accompanied by a loss of consciousness. These data may help to dispel the myth that concussion is only associated with a loss of consciousness (see Table 3).

Interview data were grouped according to observations regarding (a) physical signs and symptoms, (b) mental status, and (c) kinesthetic awareness. When asked, “How do you know when a concussion is sustained? Describe the first thing you look for,” nearly all of the coaches said the athlete’s eyes, specifically, “the pupils of the eye” (C7, C10) were the primary focal point. C2’s methods were more unique. Replying that he had been “trained real good” in a “five-minute training”, C2 described his process:

> The only way I’ve been taught is to look at his eyes… to have him shut his eyes and stay real still and if he opens his eyes and his pupils dilate, then he probably doesn’t have a head injury.

Some coaches did not seem to understand the potential seriousness of those concussions that do not result in a loss of consciousness, especially mild (Grade 1) concussions. “Bell ringers” were often not identified as concussions. Participants were asked to respond to a scenario and decide whether or not they felt a player who was “hit hard, feels dazed and confused for just a few minutes (sometimes referred to as ‘getting his bell rung’), but who is able to walk back to the huddle on his own” had suffered a concussion. 57.6% (n=38) felt that the player had sustained a concussion while 42.4% (n=28) felt that the player had not sustained a concussion. Seven participants either did not answer the question or commented that they were unsure. Concussion researchers agree that getting one’s bell rung is characteristic of mild concussion. However, it is often dismissed (11,17). At least one coach acknowledged his uncertainty:

> In my opinion and experience as a player and a coach, every player experiences at least one of the symptoms … at least once a game and practice. Where to draw the line between a real head injury and getting your bell rung is tough. (C15)

#### Return to Play Decision-making

As stated, many coaches acknowledged a duty to determine when it was safe to allow a concussed athlete to return to activity. An additional set of questions in the questionnaire sought to detect whether or not Idaho high school football coaches felt the seriousness of a concussion, formerly referred to as a grade, played a role in allowing an athlete to continue play. When asked if a player who had sustained a Grade 1, or mild, concussion should be immediately removed from a game or practice, 57.3% (n=43) said yes. 34.7% (n=26) said no, and 8.0% (n=6) stated that they did not know. When asked if a player who had sustained a Grade 2, or moderate, concussion should be immediately removed from the game or practice, 88.0% (n=66) said yes, 6.7% (n=5) said no, and 5.3% (n=4) said they did not know. When asked if a player who had sustained a Grade 3, or severe, concussion should be immediately removed from the game or practice, 94.6% (n=70) of coaches said he should, 4.1% (n=3) said he should not, and 1.4% (n=1) said he did not know. Clearly, these coaches were aware that as concussion grade increased, play/participation should be discontinued.

The coaches’ methods for determining return to play were further explored through the interviews. Responses were grouped according to those that typically make referrals to physicians and/or athletic trainers, and those that do not. Coaches who stated they had athletic trainers at their disposal said they are not involved in the decision-making process. When asked, “How do you decide when it is safe to allow an athlete with a concussion to go back into the game?” C3 abruptly responded, “We don’t decide. That’s decided by the team doctor and the trainer.”

Other coaches said they sometimes do not make referrals. C8 said he was hesitant to allow his athletes to be evaluated by physicians. He did not agree that bell ringers were consistent with concussion, nor did he agree that there was an added risk of playing through such an injury. C8 suggested doctors were too quick to diagnose a concussion and remove an athlete from play, thereby making his coaching job more difficult:

> I just think doctors are sometimes being so leery that if there’s any question in their mind then they say the kid’s got a concussion and shouldn’t play. They just don’t want to risk getting sued. There’s got to be a happy medium there.

Influencers were apparent when it came to return to play decision-making. While the majority of coaches said they would always keep the safety of the athlete as the primary focus, and that they would “err on the side of caution” and “sit players out” (C17), several coaches acknowledged the pressure to win or play, or pressure from parents, school administrators, and the athletes themselves, had, at some point, impacted their decisions. C8 said as a coach, his job was “to get the best players on the field” and that sitting players out for something as simple as a bell ringer “can get to the point where we side on the side of over-caution – to the point where it can get a little ridiculous.” C6 said it was “a little hard” to hold one of his better athletes out, “especially when the community recognizes how vital that player is to the team’s success.” C4 suggested he also might follow different rules for different kids. He told me, “When you’re a senior, you know how that works – you’ve been around athletics… you get a senior and he really wants to play.”

Participating coaches were largely unfamiliar with evidence-based concussion assessment tools. These were identified as symptom scale checklists, the Sideline Assessment of Concussion, and computerized neurocognitive assessments, such as ImPACT, HeadMinder and CogState. 56.8% (n=42) of coaches stated they never use concussion assessment tools. Of those who indicated they were familiar with the tools, 25.7% (n=19) said they were familiar with concussion symptom scale checklists, 9.5% (n=7) said they were familiar with the Sideline Assessment of Concussion, or SAC, and 6.8% (n=5) said they knew about computerized neurocognitive testing programs. No coaches were familiar with the Balance Error Scoring System. When asked how frequently they used these evidence-based assessment tools, only 18.9% (n=14) of those coaches who were familiar with one or more of the tools stated that they use them every time a suspected concussion was sustained, and 40% (n=12) said they learned about them from an athletic trainer. Of the eight coaches interviewed, only one described a research-based procedure for determining whether or not an athlete could return to play. This coach was at a 5A school with two athletic trainers. The athletic trainers at this school utilized the ImPACT concussion assessment tool:

> During the week if it’s not a game we hold the player out until they have taken a post concussion test and we evaluate their scores from when they were healthy to after the concussion has happened. Once they score equivalent to where they were prior to a concussion and they feel good and they’re cleared by the trainer or the doctor then they’re able to return. (C9)

#### Continuing Education

Participants were asked whether or not the school they coached at had provided them with training opportunities aimed at concussion and other sports injury management. 60% (n=45) stated that their school had not offered any additional training, while 40% (n=30) stated their school had. The majority stated they would be eager to learn more about the topic. 97.83% (n=72) said they would be more likely to use an evidence-based concussion assessment tool if it were made available to them at no cost. And, when asked whether or not they would be likely to participate in an educational program to teach them how to be more prepared to handle concussion injuries, 98.6% (n=71) said they would be.

#### Data Stratification by School Size
After initial analysis, the data were stratified to see whether or not trends existed relative to school size. As expected, there was a marked difference in the presence of athletic trainers based on school size. At Idaho’s largest (5A) high schools (more than 1280 students), an athletic trainer worked regularly with all football teams. By comparison, only 7% of Idaho’s smallest (1A) schools (less than 159 students) coaches stated that they had an athletic trainer. Table 4 displays these data and shows the presence of athletic trainers at the various athletic classifications (see Table 4).

The availability of athletic trainers at Idaho’s larger schools relieved coaches of the primary responsibility of concussion identification and management. C15 said, “I would rather my trainer do that and I just coach football.” C20 commented, “Having an athletic trainer has been a big relief on me on making decisions on head injuries.” Without athletic trainers, coaches inherited the responsibility. At the 1A level, 70.6% of coaches (n=12) said they were the ones responsible for identifying concussive injuries when they occur at practice. At the 2A level, 46.7% of coaches (n=7) assumed this responsibility, and 73.7% of 3A coaches (n=14) had the responsibility. By comparison, none of the 5A coaches who participated in this study acknowledged having responsibility for concussion identification and management. During game situations, coaches at the smaller schools acknowledged having more medical assistance to rely on. Physicians, nurses and EMTs were often available during games, even at the smaller schools. Because of their presence, just over 35% of 1A coaches (n=6) said they were the ones responsible for identifying concussive injuries in a game setting. Nearly 27% of 2A coaches (n=4) and 33% of 3A coaches (n=3) had this responsibility. All 4A and 5A coaches suggested the responsibility of managing concussion-related injuries was charged to either athletic trainers and/or team physicians during game situations. Table 5 displays these data and the differences between school classification in terms of concussion identification and management (see Table 5).

In Idaho, it was apparent that the smaller the school, the more likely the coach was the one who made return to play decisions. When asked who the primary person responsible for determining the appropriate time for an athlete who had sustained a concussion to return to play during practice situations was, 64.8% of 1A coaches (n=11) said they were. Again, no coaches at 5A schools had this responsibility. In game settings, the trend continued. Just over 47% of 1A coaches (n=8) reported being the person primarily responsible for determining return to play on game day, while no 5A coaches acknowledged this responsibility. Table 6 displays the disparities among the various school classification levels regarding determination of return to play (see Table 6).

When presented with the bell ringer scenario, only coaches from Idaho’s largest schools (5A) were consistently recognizing it as such. Table 7 reveals these data (see Table 7).
While beneficial when it came to managing concussion, the presence of athletic trainers did little to make coaches feel more prepared to handle the duty themselves. Coaches at the 4A and 5A levels who were also more consistent in their identification and management of concussion and who had athletic trainers at their disposal, admitted to being most uncomfortable with their ability in this area. Table 8 displays these findings (see Table 8).

Across all athletic classification levels, most coaches felt a compelling need for additional educational training when it came to managing concussion in their football programs. Not only did 1A schools not have appropriate or adequate medical supervision onsite at practices and games, it was also apparent that the football coaches at Idaho’s smallest high schools were not being provided with educational programs aimed at concussion and other sports injury management when compared to coaches at Idaho’s largest schools. Only 18% of 1A coaches stated that their school had provided them with training opportunities while 63% of 5A coaches were provided with educational outreach. Table 9 shows the data (see Table 9).

### Discussion

Since this study was limited to Idaho high school football coaches, its results may not be generalized to other states, however, findings may provide a snapshot that could provoke further inquiry into coaches’ qualifications and expertise in the area of concussion identification and management. This is consistent with the findings of McCrea et al., (16) who suggested continuing education of coaches is warranted. When it comes to concussion recognition, there is little room for error. A concussion disrupts the brain’s metabolism and the only thing that appears to help it heal is rest (17,30). This study brought to light the compelling need to do more when it comes to training coaches to adequately prepare for and manage concussive injuries. The findings spotlight the need for better concussion education programs for Idaho’s secondary sport coaches, especially those who coach at small schools with limited access to an athletic trainer or other medical personnel support. The findings also highlight the need for replicable studies in other states to determine educational needs of coaches in those areas.

The findings are discussed relative to: the persons responsible for concussion identification and management—accessibility of athletic trainers, understanding of concussion, return to play decision making and willingness of coaches to refer athletes, and continuing education. Continuing education implications derived from these findings are discussed in detail, specific to evaluation of concussion signs and symptoms, cognitive stability testing, bell ringer recognition and the ongoing need for additional first aid and concussion training.

#### Persons Responsible—Accessibility of Athletic Trainers

Consistently, coaches were charged with the responsibility of initial concussion identification and management. Some coaches also acknowledged having the sole responsibility of deciding when to allow a concussed athlete to return to play. National recommendations point to the need for athletic trainers to do this job (11,16,17). Despite these recommendations, athletic trainers were accessible to coaches at only 36% of Idaho’s high schools. This was below the 2008 national average of 42% (20). The scarcity of athletic trainers in Idaho’s smallest schools was expected. The best-case scenario would be for sport administrators to require onsite athletic trainers at sport practices and games that have significant catastrophic risks such as football. This study indicated concussion was managed more consistently and effectively at schools with athletic trainers. All 5A (large schools) coaches (n=7) who responded to this survey indicated that they had an athletic trainer who worked regularly with their football teams; and all of these coaches correctly identified a scenario involving a bell ringer as concussion and said their standard practice would be to withhold that athlete from play.

#### Understanding of Concussion, Return to Play Decision-making and Willingness of Coaches to Refer Athletes

Coaches should be informed that in cases where concussion is suspected, their primary role is to ensure medical referral for the athlete (11,16). The coaches in this study were inconsistent with regard to making referrals. While most stated they would always refer athletes with a recognized concussion to an athletic trainer or physician, some said they would rather manage the injury themselves. C8 and others seemed to lack an appreciation of the catastrophic risks associated with concussive injuries. In the past, coaches have been held liable for failing to provide adequate assistance to injured athlete. In numerous court cases, including Mogabgah v. Orleans Parish School Board (19), Stineman v. Fontbonne College (26), and Searles v. Trustees of St. Joseph’s College (23), coaches have been held accountable for their failure to recognize the potential severity of a sports-related injury.

#### Continuing Education and the Evaluation of Concussion Signs and Symptoms

Although the majority of the coaches had received basic first aid and CPR training or had identified taking a formal course in sports injury prevention, this training did not imply an understanding of concussion identification and management. Many of the coaches recognized the most common signs and symptoms of concussion, but they failed to recognize many of the more subtle signs and symptoms. While loss of consciousness, headache, disorientation, and memory loss were clearly connected with concussion, more subtle effects, like sensitivity to noise, and insomnia, were not. Concussion is an “individualized, complex injury, and … no particular symptom can provide definitive guidance for every patient and clinical situation” (11, p. 6). Therefore, even though athletes may demonstrate different signs and symptoms, it is important to consider all of the options (11). Even then, symptom scores should not be considered solely reliable. As expected, the coaches in this study relied on subjective measures of concussion assessment. However, responses to such questions like, ‘Do you have a headache’ and ‘Are you dizzy’ are not consistent or reliable indices of concussive injury. This is largely because athletes may be reluctant to report their symptoms for fear of not being allowed to play or because they do not think their injury is serious enough to warrant removal from play (16). A quick clearance and return to play based on subjective responses can increase athlete susceptibility for additional injury, including SIS (1,11,28). Conservative management of even mild instances of concussion is important in athletes under the age of 18, because almost all reported cases of SIS are in young athletes (1,11).

#### Cognitive and Stability Testing

While assessing symptoms is always warranted, baseline cognitive and postural-stability testing should also be considered for athletes playing sports with a high risk of concussion. Use of such functional tests can help to identify deficits caused by concussion and help protect players from potential risks involved with returning to play too quickly (11,17). This study’s findings reflect a lack of such assessment. Evaluation of symptoms should be supplemented with detailed questioning and functional tests, both of the brain and body (10,17). Guskiewicz, Ross and Marshall (10) concluded that simple processes, including concentration, working memory, immediate memory recall, and rapid visual processing have been shown to be mildly affected by concussion. Establishing baseline measurements before the season is recommended for comparison purposes (11,17). No coaches in this study said they conducted functional testing. In fact, none were even aware of the Sideline Assessment of Concussion or the Balance Error Scoring System. Both of these functional tools can be administered at little or no cost. Furthermore, only one coach who participated in the study was aware of neurocognitive testing programs such as ImPACT, another functional concussion assessment. He said he was aware of the test because he had heard about it being used with professional players.

#### Recognition of ‘Bell Ringers’ as Concussion

Study findings revealed coaches’ misconceptions that bell ringers or dings are not concussive injuries, and as such do not necessitate removal from play. The findings also demonstrated coaches’ beliefs that the terms bell ringer and ding carry a connotation that diminishes the potential seriousness of the injury (11,16,17). Nearly half of the coaches indicated they would allow the athlete who had his bell rung to continue physical activity. This lack of initial recognition and diagnoses supports the findings of McCrea, et al., (16), and the likelihood of athletes being allowed to continue to play while being symptomatic. Not only is SIS a factor when returning to play too soon, concussions can accumulate and lead to other long-term impairments. According to King (14), lasting verbal and visuospatial impairments have been directly linked to concussion, and athletes with a history of concussion can suffer for a lifetime from emotional changes including a difficulty to control their own anger. King (14) also contended that athletes with a history of concussion can also suffer permanent decreases in libido, sleep impairments, and can have difficulty adapting to social changes. Severe depression can also linger (12).

#### Need for Additional Training

While most state high school athletic associations require first aid and CPR training, those classes typically fall short of relaying information concerning sports-related concussion. Few states require the medical training of coaches to be supplemented to include concussion management. To date only Texas, Washington, Oregon, and Connecticut have made comprehensive training on the subject a mandate. In Texas, S.B. 82, or “Will’s Bill”, was signed into law and took effect in September of 2007. Washington’s “Zackery Lystedt Law” and Oregon’s “Max’s Law” were both passed in 2009. All three laws require youth and high school sport coaches to be trained in concussion management and cognizant of SIS. Washington’s law goes one step further. It requires a licensed health care provider to oversee each concussive injury and determine the appropriate time for the athlete to return to play (34). McCrea et al., (16) demonstrated the value of concussion education. Their study examined the reasons for the purported underreporting of concussions to high school football players. McCrea et al. concluded that players, like the coaches in this study, were not fully aware of what a concussion was. However, when provided with a definition of concussion and a description of injury signs and symptoms, the players more readily recognized the injury and were more likely to admit to sustaining concussion over the course of a football season.

No coaches in this study recalled a systematic, stepwise approach for returning athletes to play. Experts contend concussed athletes should not be allowed to return to play until all of the following conditions are met: (a) there was no loss of consciousness, (b) the athlete suffers from no amnesia, (c) the athlete is asymptomatic at rest, (d) the athlete is asymptomatic following exertion, and (e) the athlete passes all functional tests (11,17,24). The coaches in this study admitted there were other influences that convinced them to return concussed athletes to play prior to the resolution of symptoms. Some, perhaps refusing to accept responsibility or more concerned with winning, de-emphasized the importance of concussion management. Micheli, Glassman, and Klein (18) suggested coaches might feel the management of injury is not their responsibility. This was clearly the case among the Idaho football coaches in this study. In fact, one coach, C29, reiterated that “trainers are here to make the decisions and deal with the injuries, NOT THE HEAD COACHES [sic].” Because of this, coaches may have felt they needed to be less prepared to identify and manage concussion.

The lack of educational opportunities related to concussion identification and management could be the reason why these coaches are unfamiliar with the topic of concussion management. The lack of educational opportunities was most evident in Idaho’s more rural (smallest school) areas. The overwhelming willingness of coaches in this study to attend professional development workshops could be one solution. Coaches who participated in this study clearly stated they would be much more comfortable managing concussion injury if they were adequately trained to do so. When professional development occurs, it is important that knowledgeable and trained professionals teach them. With new information about concussion being discovered every year, educational workshops would be warranted annually. Such educational efforts can and should be extended beyond administrators and coaches. Parents, and even the athletes themselves, can and would benefit from learning about concussion’s subtle signs and symptoms, and the consequences involved with returning to play too soon. Perhaps then, the outside influencers and pressures coaches noted would diminish.

### Conclusions

This study revealed a lack of understanding among Idaho high school football coaches relative to concussion identification and management. Coaches were especially dismissive of instances consistent with mild concussion, or bell ringers, and their catastrophic potential. Coaches purported to address concussion management with subjective approaches that relied on athletes to self-report their symptoms. They were unaware of functional assessments that objectively measured both the brain and body. Coaches acknowledged that outside pressures contribute to their decisions on when to allow concussed athletes to resume physical activity. Their lack of understanding may be attributed, in part, to the fact that there are few athletic trainers in Idaho’s secondary schools, and there are few or no educational workshops provided to coaches on concussion management.

### Applications in Sport

While this study was limited to Idaho high school football coaches, its findings may be generalized to other coaching populations. All contact sport athletes are susceptible to concussive injury. In the absence of athletic trainers or other health care professionals on the sport sideline, it is imperative that coaches be able to recognize concussive injuries and manage them according to current published guidelines.

### Figures and Tables

#### Figure 1
Identifying Concussion Incidence: Idaho High School Football

#### Figure 2
Determining Return to Play: Idaho High School Football

#### Table 1. Thematic Constructs
Examples of Raw Data Themes and Subsequent Subthemes and Major Themes

Raw Data Theme	Subtheme	Theme
Glassy eyes. Dilated pupils.	Physical Signs & Symptoms	Recognition
Whether he’s not all together there. How cognizant they are of where they’re at.	Mental Status
Whether he’s wobbly.	Kinesthetic Awareness
It depends on the kid! Every player experiences at least one of the symptoms. I look at the severity of the hit.	Mechanism of Injury & other variables
I get him to a trainer. We have doctors on our sideline.	Referrals	Evaluation
I asked them questions, look in the eyes. We observe him for awhile. We just keep him out. We watch them very carefully.	Watch and Wait
We don’t decide. That’s decided by the team doctor and the trainer. They have to have a doctor’s release. It’s gotta be a parent.		We let him sit for awhile. Usually you go about a week and a half. We sit them out a week.	Time Away
I think we can go too overboard on it. We can get to the point where we side on the side of over-caution – to the point where it can get a little ridiculous.	It’s No Big Deal
We want to keep our best players in the game. A kid that wanted to play in the playoffs. If the parents say it’s okay, then that at least releases the coach of that (responsibility). He’s a young kid; He’s not a senior.	Pressure to Win (Play)	Influencers
I would put the safety above putting him in the game. It’s too dangerous. The kid’s health is more important than any game that we play.	Safety Comes First
We need an athletic trainer. We probably could have more – at least EMT types around for practice.	Resources	Needs
I would love the opportunity to learn more. You have to know what’s happening with your players, especially when concussion is involved.	Education
Helmet issues are going to be real paramount. The teaching of how to tackle is very important.	Equipment & Instruction

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### Corresponding Author

Caroline E. Faure, EdD
Assistant Professor of Sport Science and PE
Idaho State University
STOP 8105
Pocatello, ID 83209
<faurcaro@isu.edu>
208 282-4085

### Author Biographies

#### Caroline Faure, Ed.D., ATC

Caroline Faure, Ed.D., ATC is an Assistant Professor of Sport Science and Physical Education at Idaho State University, where she teaches undergraduate and graduate courses in sports medicine and sports law. Dr. Faure earned the prestigious Kole-McGuffey Award at Idaho State University for her research on concussion management in secondary schools.

#### Cynthia Lee A. Pemberton, Ed.D

Cynthia Lee A. Pemberton, Ed.D. serves as the Associate Dean of the Graduate School and Professor of Education/Graduate Faculty at Idaho State University. Dr. Pemberton has published and presented locally, regionally, nationally and internationally on Title IX and gender equity in school sport. Her book, More Than a Game: One Woman’s Fight for Gender Equity in Sport, addresses Title IX from both personal and professional perspectives, through a lived experience pursuing gender equity in sport at a small liberal arts college in Oregon. The book received the Phi Kappa Phi Bookshelf Award in October 2002, and has been positively reviewed in a number of publications (Journal of Legal Aspects of Sport, Women in Sport and Physical Activity Journal, Booklist and Choice).