10/6/2015

The Athletic Trainer's Nemesis: Warrior Culture

Concussions & Sports–Legal & Ethical Review: Part 8

Pressure, whether external or self-imposed, plays a major role in an athlete’s decision to report concussion symptoms


There are many reasons why a player might fail to report concussion symptoms. One is a simple lack of awareness of the symptoms that indicate a concussion has been suffered. However, the authors of the The Journal of Law, Medicine & Ethics’s report18 point to other reasons that are difficult to combat. “Not wanting to be removed from a game or practice, not wanting to let down teammates or coaches, or fearing being cut from a team or receiving less playing time,” they write.

For college athletes, there is also the impact of the cultural change from high school to college. For those participating in collision sports, this change carries with it increased risk. In addition, the coach/player dynamic has changed. “Incentives for coaches also are different at the high school and college levels,” say the authors. “Most high school coaches are teachers at the school and receive a modest income of $32,120, on average, for their dual responsibilities. In contrast, the most successful NCAA Division I college football coaches make over a million dollars per year with the potential for sizable performance-based bonuses, not to mention performance-based job security.” Playing on revenue-producing teams at major colleges comes with a new kind of pressure on the athlete—whether stated, implied, or perceived—to stay on the field.

The authors surveyed a variety of athletes to test the theory that there is resistance to self-report concussions. The results indicate that there is a hesitancy to report concussions based on the perception that teammates and coaches will view that report disapprovingly. Interestingly, freshmen indicate the belief that coaches will support their concussion report at a higher level than upperclassmen. “While there are multiple levels of influence on concussions safety, coaches can play an important role in creating and reinforcing team cultures that value concussion reporting. This study preliminarily suggests that coaches’ attitudes toward concussion reporting, or at least their attitudes as perceived by their athletes, may impact their athletes’ concussion reporting behaviors.”

Dr. Ellen Deibert, writing in Neurology,19 cites an anonymous survey in which 43% of college athletes claim to have hidden concussion symptoms from their coach or athletic trainer. The athletes note that the deception is the result of external pressures from coaches, teammates, or parents.

In December of 2014, Columbia University football coach Pete Mangurian resigned. According to ESPN, the resignation came one day after the student newspaper “reported that a letter from players was given to the university accusing the coach of verbal and physical abuse and trying to force players to play with concussions20.”

A report on Deadspin.com21 included details of the letter sent by 25 members of the team to the Columbia Spectator: “Pete Mangurian has consistently denied the diagnoses of concussions,” the letter stated. “There are several players who will speak to the fact that Mangurian told them to return to practice, that they are faking their concussions, and that they are being soft if they sit out for their concussion injury.”

Reportedly, the player letter was later retracted, and Columbia stated that their investigation found no evidence to support the allegations. Still, the possibility that there is any truth in the original players’ letter should be a major cause for concern among those charged with protecting players’ health. At the time of the resignation, Columbia was 0-10 yet, allegedly, enough pressure to win games existed to cause players and coaches to debate the legitimacy of concussion symptoms. If this can be true at a relatively irrelevant Ivy League football program enduring a winless season, then no program of any size is immune to the pressure to trivialize concussion symptoms.

Recent studies further illustrate the existence of this pressure. One survey of over 300 male and female college athletes showed that more than 25 percent experienced pressure to continue playing after a head injury.22 Around half of respondents continued playing with concussion symptoms. Interestingly, pressure from coaches was not the primary force behind the athlete’s decision-making process. Instead, it was pressure from parents that had a greater influence on whether or not a player would report concussion symptoms.

The story of Rowan Stringer exemplifies what can happen when the culture of athletics and a lack of understanding about the seriousness of TBI collide. The Ottawa high school rugby player was 17 when she died, the result of Second Impact Syndrome (in which a new brain injury was suffered while she was still recovering from an existing brain injury).23

Stringer’s texts prior to the fatal injury speak directly to the culture of “toughness” that can put a young athlete in danger. “[N]othing would stop me unless I’m dead,” she texted a friend. “[W]hat’s some brain damage gonna hurt[?]” Stringer, as captain of the rugby team, undoubtedly felt pressure to play while injured, though that pressure could very well have been completely self imposed. Testimony in her case revealed that she referred to her injuries as “warrior wounds,” though she also downplayed the urgency of the situation by noting that there are “not a lot of deaths in rugby.”

Further testimony in the case reveals the true crux of the matter. Former Canadian Football League quarterback Matt Dunigan testified that courage is required for a competitive athlete to admit he or she cannot safely play. “It would have been hard to put up her hand and say, ‘I’m injured,’” he said.

When the perceived courage of playing hurt collides with the specter of TBI, the results can be disastrous. In football, in particular, these perils are intensified by the culture of the game and its players who, in their youth, push aside thoughts of a mid-life struggle with brain damage in favor of the instinct to affirm the “warrior culture” of the sport. “The imperatives of self-sacrifice and self-denial for the sake of the team, and the machismo of ignoring even intense physical pain, naturally — perhaps inevitably — lead players to downplay insults to the body, in order to not be regarded as weak in both body and spirit by their teammates and coaches,” write the authors of the Journal’s section on informed consent.24

Issues of loyalty to teammates, and the power differential that typifies the player/coach relationship, further exacerbate the willingness of the player to downplay a concussion. This isn’t helped by the fact that concussions have long been shrugged off as a “getting one’s bell rung,” a term that suggests a temporary annoyance, rather than the reality of brain damage. In telling the story of Matt Gfeller, a 15-year-old who died after a helmet-to-helmet collision in his first high school football game, the authors note the crux of the problem: “Matt’s love of both watching and playing football... provide(s) another illustration of the ways in which the culture of the game conflates toughness and loyalty, helping to demonstrate how difficult it can be for young men and their parents to buck the football trend.”



18Christine M. Baugh, M.P.H., et al, “Perceived Coach Support and Concussion Symptom-Reporting ,” The Journal of Law, Medicine & Ethics, 42:3 (2014): 314 - 322.
19Ellen Deibert, MD, “Concussion and the neurologist ,” Neurology, 83:4 (2014): 300 - 301.
20“Columbia’s Pete Mangurian Resigns,” last modified December 5, 2014, www.espn.com.
21“Columbia Footballers: Coach Forced Us To Play Through Concussions,” last modified December, 4, 2014, www.deadspin.com
22“Athletes Report Pressure to Keep Playing After a Head Injury,” last modified April 23, 2015, http://www.psmag.com/health-and-behavior/athletes-report-pressure-to-kee....
23“Rowan Stringer ignored concussion symptoms days before death,” last modified May 20, 2015, http://www.cbc.ca/news/canada/ottawa/rowan-stringer-ignored-concussion-s....
24Richard Robeson, B.A., C.P.F.T., and Nancy M. P. King, J.D., “Loss of Possession ,” The Journal of Law, Medicine & Ethics, 42:3 (2014): 334 - 343.

A Legal & Ethical Review of CONCUSSIONS & SPORTS
A Legal & Ethical Review of CONCUSSIONS & SPORTS
Key Takeaways for the Athletic Trainer, Athletic Director, Coach, Heath Care Provider, and Parent