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 4–6 7,8
Advances in concussion knowledge, awareness, and reporting behaviors have been reported in drivers from the United Kingdom (9
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 13 14 15,16
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 −1 , the resultant impacts can lead to a concussion despite the safety equipment within race cars (2 20
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
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
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.
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
a
b
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
a
b
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 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 13 23 24,25
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 23 23 21 20
Reporting Behaviors
Previous research suggests that suspected concussion disclosure may not reflect athletes’ knowledge and attitudes of the injury (20 9 26 26 27 26
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 29 13 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
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 32 31 31
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 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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