This study examined the rate of reported concussion symptoms after head trauma in NCAA division 1 wrestlers. In addition, we tested knowledge of possible concussion symptoms in these athletes. An anonymous 6-question survey was administered to active college wrestlers 18+ who have participated in greater than 50% of their past 3 wrestling seasons. The survey assessed concussion knowledge, history of concussive signs and symptoms, and history of reported concussions. Self-reported incidence of concussive signs and symptoms, reported concussions, and concussion knowledge were used as outcomes. 56.7 % of respondents were able to identify all the symptoms on the concussion symptoms list designed to test baseline knowledge levels. 22 out of the 30 respondents reported one or more possible concussion incidents, which totaled 35 in the study. Only 14/35 (40%) were actually reported to a medical staff. 11 of those 14 wrestlers (78.6%) went on to be formally diagnosed with a concussion. Concussion symptom identification accuracy is low (56.7%) and underreporting of symptoms rate is high (60%) in this subset of athletes. These findings may warrant further education regarding concussion and concussion reporting amongst division 1college wrestlers.

Concussion, Reporting, Wrestlers, Wrestling, Survey

Berri H, Pastrnak J, Scheff K, Kiningham B (2018) Prevalence of Concussion Symptom Underreporting in NCAA Division 1 College WrestlersAn Observational Study. Ann Sports Med Res 5(2): 1133.

SRC: Sports Related Concussion; TBI: Traumatic Brain Injury; NCAA: National Collegiate Athletic Association; AANS: American Academy of Neurological Surgeons; IRBMED: Institutional Review Board of the Medical School NFL: National Football League

Sports related concussion (SRC) is a type of traumatic brain injury (TBI) induced by biomechanical forces that are caused by a direct blow to the body with forces transmitted to the head that results in a rapid onset of short-lived impairment of neurological function that usually resolves spontaneously [1]. Physiatry has been on the cutting edge of evaluation and management of TBI and SRC. Recent data from the NCAA Injury Surveillance program indicates that college wrestlers had the highest concussion rate per athletic exposures compared to 12 other sports, including ice hockey and football [2]. The rate of injury in wrestling may range from 16.3-69.5 per 1000 athletic encounters, and concussion in the sport may compose 25-27% of these injuries [3]. It has been speculated that concussion symptoms are underreported by athletes [4,5], but there is a paucity in literature, particularly in regards to division 1 college wrestlers.

In a study of 156 NCAA division 1 athletes from multiple sports, the most commonly endorsed reasons for hiding symptoms were related to severity downplaying, loss of athletic standing, and perceived interpersonal pressures [5]. Another interesting finding in this study was that authors considered this cohort of mixed athletes to have “considerable” concussion symptom knowledge even though 43% of athletes scored lower than 80% correct on their concussion symptoms knowledge test [5]. Also, the proportion of wrestlers in this study was not disclosed. Another study that included primarily male division one football players showed underreporting of post-concussive symptoms to team medical staff in the days immediately following a concussion after a diagnosis had been made [6]. No collegiate wrestlers were involved in this study. Other studies speculate that underreporting is due to fear of being withdrawn from competition, underestimating severity of injury, and/or lack of recognition of concussive symptoms [4,7]. Fedor and Gunstad examined concussion knowledge in division 1 athletes, and there were no significant differences in the knowledge of number of symptoms to be expected after concussion between division one wrestlers and students who were not athletes [8]. They go on to suggest that student-athletes may have an incomplete understanding of concussion-related symptoms, and future studies are needed to determine whether formal education sessions can improve knowledge for this high-risk population [8].

We conducted a survey of NCAA division one wrestlers to assess basic knowledge of identification of possible concussion symptoms. We compared the incidence of possible concussive signs and symptoms in wrestlers immediately following head trauma, to the incidence of medically diagnosed concussion in these same athletes. We hypothesized that possible concussion symptoms would be under reported or withheld from medical personnel, and that this may be related to incomplete knowledge of concussion symptoms, among other factors noted above.

57 NCAA Division 1 college wrestlers from two separate universities were invited to respond to an anonymous 6-questions survey (Appendix 1). Inclusion criteria included age 18 and older, Division 1 college level wrestlers who had wrestled in at least 3 consecutive competitive wrestling seasons. Exclusion criteria included wrestlers who had participated in less than 50% of the last 3 seasons due to other injuries or other factors not related to concussion. The University of Michigan IRBMED granted an exemption, #2, for this study. Ethics approval was obtained from each wrestling team’s institution and consent was obtained prior to respondents completing the survey. Data collection took place from February to May of 2017. Surveys were distributed to wrestlers by their respective athletic trainers in a pre-practice or training room environment.

The survey assessed knowledge of concussion symptoms using the American Academy of Neurological Surgeons (AANS) concussion symptom list, which warrants prompt evaluation by a healthcare professional [5]. Respondents selected which symptoms, of the 11 listed, were thought to be related to concussion by checking off yes or no on the form. No controls or incorrect symptoms were listed. We then asked respondents to report how many times they experienced wrestling trauma to the head/neck/face followed by 1 or more symptoms from the AANS concussion symptoms list in the last 3 years, which we defined as an “incident”. Respondents recorded how many of those incidents were reported to a healthcare provider such as an athletic trainer or physician and how many times respondents were actually diagnosed with a concussion by a physician as a result. Exposure to concussion risk was calculated by the respondent’s self-reported average number of months per year they trained in wrestling over the last 3 years as shown in Figure 1.

30 wrestlers completed the questionnaire. As seen in Figure 1, they averaged 10.9 months of wrestling training per year over the last 3 years. 17 respondents out of 30 (56.7 %) were able to identify all the symptoms on the AANS concussion symptoms list. The concussion symptoms that were least commonly identified by respondents were anosmia and aguesia. 22 of the 30 respondents (73.3%) reported 1 or more incidents of concussion symptoms after trauma to the head/face/neck region, totaling 35 incidents, as seen in Figure 2. Of the 35 possible concussions, only 14 (40%) were reported to a healthcare provider. Of those 14 reported incidents, 11 went on to be formally diagnosed as a concussion by a physician (78.6%) (Figure 3).

In prior epidemiologic studies of concussion and concussion reporting there have been concerns for underreporting [6,7]. As seen in Figure 3, 21 incidents out of the 35 incidents of possible concussion (60%) went unreported. The results of this study are similar to findings in a study by Kerr et al., in which former NFL football players were surveyed and found to have 50.3% of respondents’ report they had sustained a concussion and did not inform medical staff, at least once, during their professional playing career [11].

The reasons for underreporting/withholding reporting of symptoms in division 1 college wrestlers must be explored further, but incomplete knowledge of the signs and symptoms of concussion in may play a role. Only 56.7% (17/30) of respondents in our study thought that all the symptoms listed on the AANS concussion symptoms list could be symptoms of concussion. It is possible that this lack of knowledge is related to the observed underreporting. In turn, there may be a need to focus on further educating athletes on concussion symptoms to be aware of after trauma to head, neck, and/or face. Other reasons for underreporting may be due, in part, to the highly competitive environment of intercollegiate wrestling with pressure on athletes to continue to train and compete despite discomfort or injury, although more research in this area may be needed.

It may be worth noting that in the sport of wrestling in particular, where weight cutting is standard practice, dehydration 

Figure 1: Average months per year training for each wrestler.

Figure 2: Incidents of head trauma with concurrent AANS symptoms.

Figure 3: Incidents encountered, self-reported, and those who went on to be formally diagnosed as concussion.

has been found to have a negative effect on wrestler performance on various clinical concussion measures [9]. This may confound concussion reporting and diagnosis in this group and should be taken into account. Another limitation is the possibility of recall bias given the time frame of recall required for reporting events over the last 3 wrestling seasons.

In the future, this survey can be given to a larger number of wrestlers, at a larger variety of colleges to see if these trends continue to hold true over a larger sample size. This survey can also be given to other sports as well to look for trends in concussion symptom reporting habits and actual diagnosis rates.

There was a high degree of underreporting/ withholding of possible concussion symptoms after head/face/neck trauma amongst division 1-college wrestlers. There was also a lack of basic baseline knowledge of possible concussion signs and symptoms amongst these athletes.

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