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Original Investigation

Concussion Knowledge, Attitudes, and Reporting Behaviors of Sports Car Racing Drivers

Bretzin, Abigail C.1; Hines, Julia N.D.2; Ferguson, David P.3

Author Information
Translational Journal of the ACSM: Spring 2022 - Volume 7 - Issue 2 - e000195
doi: 10.1249/TJX.0000000000000195
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Abstract

INTRODUCTION

Automobile racing (motorsports) is globally popular with a viewing audience equal to soccer, yet unlike soccer, there is a paucity of sports medicine literature related to motor racing participants (1–3). Although a health care team is present at the elite competition series, the junior ranks of motorsports have variability in health care accessibility. In addition, the financial burden of motorsport participation often falls on the racing driver in junior levels, yielding limited funding for appropriate onsite health care professionals (e.g., athletic trainer, physical therapist, medical doctor, nutritionist, or exercise physiologist). The lack of qualified onsite medical personnel warrants studies investigating knowledge of the treatment and management medical conditions, including concussion. Early recognition and diagnosis of concussion are optimal for concussion management because delayed diagnosis predisposes prolonged recovery (4–6) and worsens severity (7,8). However, concussion detection in motorsports is challenging because of access to racing drivers during events.

Advances in concussion knowledge, awareness, and reporting behaviors have been reported in drivers from the United Kingdom (9). However, these were in primarily open wheel racing drivers, where a single driver pilots the vehicle. In sports car racing, multiple drivers share a single vehicle, and this cultural dynamic could have different concussion knowledge, awareness, and reporting behaviors. Specifically, sports car racing places a higher demand on preventing damage to the race car as compared with open wheel racing in the United Kingdom.

The Pirelli World Challenge (PWC) series is a sports car racing series in the United States where competing drivers have a variety of experience levels, enabling researchers to robustly characterize concussion knowledge, attitudes, and reporting behaviors in a setting that has not been documented previously in the peer-reviewed literature.

Literature on knowledge, attitudes, and reporting behaviors of concussion exists in a variety of athletic settings (10–13). Importantly, athletes without access to an athletic trainer display lower knowledge of concussion than athletes with athletic trainer access (13). Moreover, approximately 50% of former professional athletes recall at least one concussion that they did not disclose (14), with injury severity, knowledge, and not missing game or practice play continuously being the most common reasons for nondisclosure (15,16). To date, limited studies investigate the knowledge, attitudes, and concussion-reporting behaviors (reasons for disclosure and nondisclosure) of athletes in extreme motorsports.

During motorsports, drivers are under physiological stress that is manifest by a 2°C–3°C increase in core body temperature, heart rates at 55%–80% maximum, and a caloric expenditure of 1300–1700 cal depending on the length of the race (1,2,17–19). Prolonged exposure to these stressors increases the incidence of fatigue, which can result in a driving mistake or crash. Because racing cars easily reach speeds of 273 km·h−1, the resultant impacts can lead to a concussion despite the safety equipment within race cars (2). Moreover, the culture of motorsports is likely different from that of traditional sports, which may influence knowledge, attitudes, and reporting behaviors of concussion (20). Identifying if racing drivers are able to recognize the signs and symptoms of a concussion, and understanding reporting behaviors within the sport may help direct health care initiatives specific to concussion in the sport. Therefore, the purpose of this investigation was to describe knowledge and attitudes of concussion and reporting behaviors of PWC racing drivers.

METHODS

Research Design

This was a cross-sectional survey of racing drivers approved by the institutional review board (Legacy 17-1115) at Michigan State University, which ensured that driver privacy and confidentiality was maintained. Subjects were informed of study procedures and signed a University-approved informed consent document. Data collection occurred during the 2017 PWC racing season (March to September). The survey collected information about racing driver knowledge, attitudes, and recalled concussion events and reporting behaviors of concussion. The survey took less than 20 min to complete, and drivers were not compensated for participation.

Sample and Participants

In the 2017 season, 85 drivers competed in PWC. The research team was allowed to make a verbal announcement at the drivers’ meeting to recruit subjects. A sample of 59 (57 males, 2 females; age, 39.78 ± 13.3 yr; range, 18–71 yr) drivers resulted from this recruitment that completed the survey (69% of total drivers were surveyed). Table 1 displays driver descriptive and demographic information.

TABLE 1 - Participant Demographics.
Characteristic Mean SD
Age (yr) 39.78 13.3
Years driving (professional and amateur) 13.27 9.0
n %
Sex
 Male 57 96.6
 Female 2 3.4
Discussed concussion information (n = 59)
 Athletic trainer 16 27.1
 Personal trainer 5 8.5
 Spouse/significant other 13 25.0
 Doctor 20 33.9
 Team member 6 10.2
 No one 22 37.3
 Other 7 11.9
History of concussion across lifetime (n = 57)
 Yes 19 33.3
History of concussion in a race car or cart (n = 59)
 Yes 7 11.9
History of “bell-ringer” or ding in a race car or cart
 Race (n = 59) 18 30.5
 Practice or qualifying (n = 58) 10 17.2

Instrument

A single, validated survey (Cronbach α = 0.72–0.80) by Register-Mihalik et al. (21) was modified for the motorsport setting. A series of 42 items assessed general knowledge of concussion, symptom recognition, complications of multiple concussions, and returning to sport with a suspected concussion. A total knowledge score was calculated by summing the total number of correct responses for each question (possible range, 0–42). In addition, a seven 7-point Likert-scale (1 “not important” through 7 “very important”) assessed overall concussion attitudes, education, and reporting. The total attitude score was calculated by summing responses (possible range, 7–49), with higher scores representing more favorable attitudes. Participants also rated their agreement on a 5-point Likert scale (1 “completely disagree” to 5 “agree completely”) for “I understand the dangers of concussions” and “I know the signs and symptoms of a concussion.”

Racing drivers also recalled prior concussion and concussion-like events (i.e., “bell-ringer”) during their lifetime and during their driving history (e.g., race, practice, or qualifying). Previous investigations used recollection of previous bell-ringer events to describe a potential concussion (21). Finally, drivers were asked if compete if they thought they were experiencing signs and symptoms of a concussion.

Statistical Analysis

This is a descriptive report of a cohort of racing drivers. Statistics include frequencies and percentages, and medians and SD described demographics, general knowledge scores, attitude scores, and reporting behaviors. Reasons for disclosure and nondisclosure were described for participants with a history of at least one possible driving-related concussion or bell-ringer event. Descriptive statistics were performed using Stata (version 16; StataCorp, College Station, TX).

RESULTS

A total of 59 PWC series racing drivers (male: n = 57/59, 96.6%) completed the survey. Racing drivers indicated they understood the dangers of concussions, as scores ranged from 3 to 5 (4.64 ± 0.6) out of 5. Similarly, racing drivers suggested they knew signs and symptoms of a concussion, as scores ranged from 2 to 5 (3.86 ± 1.0) out of 5. Table 1 displays complete demographic information.

Concussion Knowledge and Attitudes of Racing Drivers

Total knowledge scores averaged 34.65 ± 4.7 (range: 20–40), and total sign and symptom recognition scores ranged from 11 to 26 (21.59 ± 4.1); higher scores indicated greater knowledge. The most commonly recognized signs and symptoms included confusion (94.4%), headache (92.6%), and loss of consciousness (90.7%); the least recognized was sleep problems (48.2%). Symptom recognition is presented in Fig. 1. A majority (87.5%) correctly identified that individuals should not return to play with a suspected concussion; however, 66.7% incorrectly identified paralysis as a complication of returning to play too soon. Table 2 presents individual knowledge items. Total attitude score averaged 45.11 ± 3.5 (range: 33–49); higher scores indicated attitudes that are more favorable. Table 3 presents individual attitude items.

F1
Figure 1:
Concussion signs and symptoms recognition of sport car racing drivers.
TABLE 2 - Concussion Knowledge of Sport Car Racing Drivers.
Concussion Knowledge Item Correct Response
n % a
General knowledge
 A concussion only occurs if you lose  consciousness “black out.” (false)  (n = 56) 52 92.9
 If you are experiencing any sign or symptom of a concussion following a blow to the head or sudden movement of the body, you should not return to play. (true) (n = 56) 49 87.5
 A concussion is an injury to the _______. (brain) (n = 55) 51 92.7
Multiple concussions: Of the following, what are the complications of having multiple concussions? b (n = 52)
 No complications exist (false) 51 98.1
 Increased risk of further injury (true) 42 80.8
 Brain damage (true) 49 94.2
 Joint problems (false) 48 92.3
 Memory problems (true) 47 90.4
 I don’t know (false/not checked) (n = 55) 48 87.3
Returning to play too soon: Of the following, what are possible complications of returning to sporting activity while still experiencing possible concussion symptoms? b (n = 51)
 No complications exist (false) 51 100.0
 Increased risk of further injury (true) 47 92.2
 Paralysis (false) 34 66.7
 Brain damage (true) 47 92.2
 Joint problems (false) 47 92.2
 I don’t know (false/not checked) 47 92.2
 Total knowledge score (mean ± SD) 34.65 ± 4.7
aPercentage of correct responses representing the proportion of the sample responding to each item.
bCheck all that apply.

TABLE 3 - Sport Car Racing Drivers (n = 57): Concussion Attitude Items and Descriptives.
Attitude Item (Rated on a Scale of 1 “Not Important”–7 “Very Important”) Mean SD
How serious you think it is when you experience a headache and dizziness following a blow to the head or body 5.97 1.2
How important you think it is not to participate in physical activity (race or practice) when experiencing signs and symptoms of concussion 6.21 1.2
How important you think it is to be informed about how concussions happen 6.63 0.7
How important you think it is to be informed about how concussions can be prevented 6.63 0.8
How important you think it is to be informed about what to do if you have a concussion 6.84 0.5
How important you think it is to report possible concussion to a medical professional (doctor, athletic trainer, etc) or a team member/owner 6.84 0.6
Your level of agreement with the following statement: In general, athletes are undereducated (don’t know enough) about concussion 5.98 1.2
Total attitude score 45.11 3.5

Concussion Nondisclosure and Reasons for Reporting

Fifty-seven PWC drivers completed questions regarding concussion or bell-ringer event reporting behaviors; 29 drivers (50.9%) reported at least one possible driving-related concussion or bell-ringer event. Seven recalled concussions occurred during a race, and three occurred during a practice or qualifying. Drivers recalled 26 bell-ringer events in a race and 14 bell-ringer events in practice or qualifying. Of the 29 drivers with a previous concussion, 16 (55.2%) indicated they disclosed this information to a medical professional or teammate. Table 4 presents common reasons for disclosure and nondisclosure. Of the 29 drivers who reported at least one driving-related concussion or bell-ringer event, 3 (10.3%) reported to continue to drive during a race, and 1 (3.4%) reported they continued to drive in practice or qualifying with signs and symptoms. In the total sample (n = 59), 10 (17.0%) indicated that they knew a teammate who had a concussion that remained undisclosed.

TABLE 4 - Sport Car Racing Drivers’ Concussion-Reporting Behaviors.
n %
Disclosure a (n = 29)
 Did not want to have any further damage to their brain 9 31.0
 They thought that they had a concussion 6 20.7
 They were scared 4 13.7
 They felt the same way they did when they had a previous concussion 1 0.6
Nondisclosure b (n = 13)
 They did not want to have to go to the doctor 2 15.4
 They did not think it was serious 2 15.4
 They had a chance at winning the championship when it happened 2 15.4
 They did not want to let their team down 1 7.7
 They did not know at the time it was a concussion 1 7.7
 They thought their spouse/significant other would be upset 1 7.7
aReasons for disclosure includes 29 drivers reporting at least one possible concussion or “bell-ringer” event.
bSixteen drivers indicated disclosure of all concussions; therefore, reasons for nondisclsoure includes the 13 drivers who did not report all suspected concussions.

DISCUSSION

There are limited studies on motorsport athletes, especially regarding concussion, despite the conditions in motorsports that increase the risk for concussion and other bodily injury. The present investigation was an exploratory study of knowledge and attitudes of concussion among a cohort of racing drivers. The main finding was that a large proportion of drivers were correctly able to recognize common signs and symptoms of a concussion, correctly answer general concussion knowledge questions, and understood the dangers of multiple concussions and returning to their sport too soon. Importantly, it was identified that over half (n = 16/29, 55.2%) of drivers recalled a previous concussion and indicated that they disclosed their injury to a medical professional or teammate.

The results also suggest that nondisclosure behaviors occur in the motorsports setting. The most common reason that a driver chose to disclose their signs and symptoms of a concussion was that they did not want further brain damage, whereas the most common reason for nondisclosure was that drivers did not want to go to the doctor and did not think it was serious. Therefore, there should be more education to inform drivers of the serious of concussion. Unfortunately, the survey tool did not elucidate reasons for not wanting to go to the doctor. Future investigations should probe this reasoning to improve concussion treatment in drivers. However, because sports medicine is limited in motorsports, it could be speculated that drivers associate visiting the doctor with not be able to drive the car. Perhaps if there was a greater sports medicine presence at all levels of motorsports, drivers would not have a negative connotation with doctors.

Concussion Knowledge and Attitudes

The results suggest that racing drivers had strong general knowledge of concussion and were similar to recent reports of athletes participating in traditional sports (11–13,20). Increased awareness due to heightened attention toward concussion in recent years may explain the strong general knowledge and favorable attitudes toward concussion. Drivers most commonly recognized confusion, headache, and loss of consciousness as correct signs and symptoms of concussion. In traditional school-based athletics, headache, confusion, and loss of consciousness are also signs and symptoms most often identified by athletes (10,11,13,22).

The present investigation indicated that no driver correctly identified all potential signs and symptoms of a concussion. In addition, the only sign or symptom recognized by less than 80% of participants was sleep problems. Sleep problems as a result of concussion are often among the least recognized signs and symptoms by athletes (22), especially those without access to an athletic trainer (13). In a similar sample, only 36% of amateur motocross riders correctly identified trouble sleeping as a potential symptom of concussion (23). Because sleep quality may influence concussion recovery, it is important to continue to educate athletes on the importance of sleep when being treated for a concussion (24,25). The ability to identify all signs and symptoms of concussion is especially relevant to athletes participating in extreme motorsports because of heavy reliance on subjective symptom reporting and the potential risk of personal and peer injury or catastrophic event because of continued driving with a suspected concussion.

Our results further demonstrated strong general knowledge of concussion, in which over 80% of respondents correctly answered general knowledge questions; this is similar to findings of Miller et al. (23) indicating that the majority of amateur motocross athletes correctly answered general knowledge questions. However, 92% of amateur motocross athletes incorrectly answered if a rider suffers from a concussion; it is important to keep them awake (23). Pairing driver education to current concussion management protocols may help to fill in the gaps of misconceptions of concussive injuries in this population. In addition, 41% of the sample incorrectly unrecognized that a physician or health care provider should evaluate a bell-ringer (23). Bell-ringer is a common term used by athletes and has previously been used in research to identify potential concussions that may remain undisclosed or undiagnosed, as an athlete may not have sought out medical care. We found that drivers reported previous bell-ringer events more frequently than concussion events, suggesting potential issues in current reporting behaviors. Not all bell-ringer events may result in a true concussion diagnosis; however, their presence may warrant medical attention for appropriate management (21). Therefore, future education of athletes in motorsports should address and clarify common terms and the definition of concussion to reinforce positive reporting behaviors for suspected concussive injuries (20).

Reporting Behaviors

Previous research suggests that suspected concussion disclosure may not reflect athletes’ knowledge and attitudes of the injury (20). Therefore, we asked participants to recall former concussion events that they both disclosed and did not report. In the present sample, over 50% of racing drivers recalled at least one possible concussion or bell-ringer event during a race or practice/qualifying event. These results are higher than 32% of racing drivers in the United Kingdom who reported a concussion experience (9). Previous literature has used the socioecological framework to explore athletes’ decisions for concussion disclosure including intrapersonal, interpersonal, environmental, and policy levels (26). The present investigation found that drivers disclosed reasons for both why they did and did not disclose signs or symptoms. The most common reason for disclosing included the following: they did not want to have any further damage to their brain, they thought that they had a concussion, and they were scared, encompassing the interpersonal level of the socioecological framework (26). However, in a sample of military cadets, the most influential factors of intention to report concussion were favorable perceived peer social norms, attitudes about concussion, and control over disclosure (27). These results and of the current study suggest that favorable reporting behaviors encompass multiple levels of the socioecological model (26), indicating that continued formal and nonformal educational interventions should incorporate each level of the socioecological framework.

Most previous research has primarily investigated reasons for nondisclosure. For example, in former collegiate athletes, the most common reasons for nondisclosure included not wanting to leave a game or practice, not wanting to let the team down, not knowing their injury was a concussion, and not thinking that the injury was serious enough (28). Similarly, in collegiate club sport athletes, most common reasons for nondisclosure included not thinking it was serious, not wanting to lose playing time, not knowing it was a concussion, and not wanting to let the team down (29). In our sample, 44.8% drivers with a self-reported concussion history indicated nondisclosure of suspected concussions, and the most common reason for not reporting was that they did not want to have to go to the doctor. Wallace et al. (13) identified that high school athletes without access to an athletic trainer were more likely to not report a concussion because they did not want to go to the doctor compared with those with access. Thus, access to onsite trackside athletic training services, or other qualified medical professionals, may improve reporting behaviors as drivers would not have the fear of being removed from the race car (30).

The reasons for nondisclosure in the present investigation support the use of the multilevel socioecological framework when trying to understand concussion-reporting behavior. For example, this framework includes social features (27), and favorable perceived social norms demonstrate higher intentions to disclose. However, in this setting, social factors may be a deterrent to reporting because driving, or the removal from driving, has social and financial implications on these athletes’ everyday lives. More than 55% of surveyed high school and college athletic trainers indicated that restricting highway driving may influence concussion disclosure. Approximately 60% of athletic trainers agreed that driving is socially important, and only 22% agreed that postconcussion driving restrictions may socially harm patients and may affect their recovery. However, this information comes from athletic trainers in more traditional sport arenas and does not include the views of those in which driving is a part of the sport. Therefore, in the motorsport setting, both the social and financial components of driving my influence suspected concussion reporting, warranting further research.

Concussion and Driving Performance

Detecting concussion in racing drivers and removing them from sport participation are critical for safety. After a concussion, individuals demonstrate poorer control of a street going vehicles compared with controls (31) and are slower to respond to driving hazards, yielding risks for both concussed driving participants and those on the road. Removing drivers suspected of a concussion from participation will aid in preventing the concussed driver from increasing his/her risk of enduring a second impact and further injury, and endangering others on the road from concussion-related crash on track. A study assessing fitness-to-drive road cars found cognitive difficulties at 24 h after concussion (32), advocating for concussed patients to refrain from driving road cars for at least 24 h after concussion. High school and college athletic trainers most often use symptom duration in determining how long an athlete with a concussion should refrain from driving (31); yet, these results do not include athletes participating in motorsports. Despite limited research in this population, recent evidence suggests that return to driving may not be appropriate even after symptom resolution, as deficiencies in vehicle control and neuropsychological assessments related to driving performance are still found in patients who were reported to be asymptomatic (31), warranting further research.

Limitations

One limitation of the present investigation was the self-reported nature of concussion history of racing drivers. Drivers recalled previous concussions; however, previous concussions are subject to recall bias because they may have gone unrecognized or underreported. In addition, drivers did not report the dates of disclosure/nondisclosure, and therefore, we cannot determine other contributing factors to reporting (i.e., year of incident). The participants had a wide range in age and years of driving experience, which, because of a shift in societal concussion awareness in recent years and asking drivers to recall events across their career, may have influenced the results. We asked drivers if they previously discussed concussion information with a list of individuals; however, this is also subject to recall bias, and the depth of these conversations is unknown. To date, there is no known formal concussion education program within motorsports, and therefore, we were not able to compare differences in drivers with or without formal concussion education. Moreover, the present investigation only included a subset of semiprofessional motorsport driving types (e.g., professional and amateur racers) participating in the PWC series. Further evaluation of the junior/entry level series is required for evidence-based practices regarding concussion education. Lastly, the investigation had a small sample size in comparison to similar investigations in sports that are more traditional; however, in motorsports, this sample size is large. In fact the foundational article in motorsport physiology had an n = 7 (33), with large sample sizes consisting of n = 10 (34,35).

Conclusions

This study discusses the level of knowledge and attitudes toward concussion in motorsports and describes concussion-reporting behaviors in a sample of motorsport drivers. Drivers correctly identified common signs and symptoms of a concussion and had favorable general concussion knowledge and attitudes. Of those recalling a previous concussion, over half indicated they reported their injury to a medical professional or teammate; however, nondisclosure behaviors were still present in this setting. A common reason for nondisclosure was not wanting go to the doctor, illustrating benefits of continued presence of medical coverage at race venues. The application of the present investigation will inform the health care team working at racing events to help manage concussions. Future research should explore the incidence of concussion that occurs in varying levels of professional and amateur motorsports, and educational initiatives for concussion knowledge in the motorsport setting.

Authors Abigail C. Bretzin and Julia N. D. Hines have contributed equally to be classified as lead author. The results of the present study do not constitute endorsement by the American College of Sports Medicine. In addition, the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation.

There are no conflicts of interest to report. The authors are supported by funding from Penn Injury Science Center R49CE03083 (A. C. B.), Brain Injury Training Grant NS043126 (A. C. B.), and Michigan State University Department of Kinesiology startup funds (D. P. F.).

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