Abstract

This study’s purpose was to investigate the differences among student-athlete and adult perceptions of the Return-to-Play program.  Prior research showed that athletic trainers believe Return-to-Play is essential in the concussion-recovery process; however, research has not been conducted which analyzes student-athletes’ opinions of the efficacy of Return-to-Play.  This study utilized qualitative survey research and a proportionally-stratified sample, which included 22 student-athletes, 5 athletic trainers and 4 coaches of contact sports in Suffolk County, New York. Initial results showed that participants perceived Return-to-Play to be useful in healing from a concussion.  Therefore, the conclusion can be made that students and adults favor utilizing Return-to-Play in the concussion-rehabilitation process; however, this is limited due to the small sample size and the presence of self-reported data in this study. Future research should include a study of the perceptions of 16-24 year-old student-athletes in New York, which requires participants to have suffered a concussion within the year prior to starting the study.  This research is crucial in creating a safer environment in contact sports, by demonstrating ways to recover from injuries suffered during play.

Perceptions of the Return-to-Play Program

Introduction

The rate at which young children participate in contact sports has been on an overall decline since the discovery of the serious impacts of the symptoms caused by mild traumatic brain injuries (Tremblay et al., 2018).  This wave of realization that concussions could have potentially fatal effects began in the 1980s with the discovery of second-impact syndrome by Robert Saunders and Ronald Harbaugh. The injuries caused by multiple head traumas including: anxiety, depression, balance and vision issues, consistent headaches, suicidal thoughts and eventually death, further indicate the severity of sports-related concussions (Saunders & Harbaugh, 1984).  Brain injuries were further analyzed and investigated throughout the late twentieth and early twenty-first centuries and several substantial revelations, including the implementation of a recovery procedure for concussed athletes were made. The first iterations of the concussion-recovery program began as a fundamental guide for these athletes, but needed improvement to allow players to return to physical activity safely and later developed into what is now known as the Return-to-Play program.  

The Return-to-Play program is especially important to examine because this program is the only concept that is preventing athletes that have recently suffered a concussion from continuing to “play through the pain”, leaving themselves at an exponentially greater risk not only for enduring a second head injury, but also a prominent risk for a fatality (Saunders & Harbaugh, 1984).  In order to explore the efficacy of the Return-to-Play protocol for concussed athletes, the researcher surveyed student and adult opinions of this procedure, by asking them if they have felt the program was helpful in eliminating any concussive symptoms from lingering to the extent that they affected the athlete on a daily basis. A study which explored the perceptions of various athletes, coaches and athletic trainers (ATCs) surrounding the Return-to-Play protocol was necessary to identify if there was a requirement to alter this procedure in a manner that benefits concussed athletes more than Return-to-Play does currently.

Literature Review

General Short-Term Effects of Sports-Related Concussions

In 1984, Robert Saunders and Ronald Harbaugh conducted a study that found what is now widely known as Second-Impact Syndrome (SIS).  “Consisting of two separate events, an athlete usually suffers post-concussive symptoms following a head injury, then, within several weeks, the athlete sustains a second head injury resulting in the diffusing of cerebral swelling, brain herniation, and possible fatality” (Saunders & Harbaugh, 1984).  Due to their discovery of SIS, Saunders and Harbaugh presented guidelines for appropriate follow up and evaluation by a specialist when necessary. The neuropsychologists (See Appendix A) concluded that the player should not be allowed to return to regular physical activity if certain signs including headache, nausea, feeling “in a fog”, as well as differences from a patient’s baseline, are present.  

Similarly, Theriault, De Beaumont, Tremblay, Lassonde, & Jolicoeur (2011) employed the Sustained Posterior Contralateral Negativity (SPCN) waveform component (See Appendix A) while the participants of their survey completed various visual short-term memory tasks.  Their goal was to research how multiple concussions affected the working memory of the participants who have suffered at least one mild traumatic brain injury. They found that the athletes with three or more concussions had significantly worse working memories; however, their hypothesis was proven incorrect, since they concluded the correlation between concussions and the deterioration of their working memories was not strong, meaning the degradation could be from other factors, like aging (Theriault et al., 2011).  The inability of prominent neurologists and researchers to come to consensus about the impacts of sports-related concussions (SRCs) on an athlete’s brain (See Appendix A) has led to significant controversy over the safety of contact sports. Theriault et al. (2011) also suggested that continued research on the growing presence of SIS in contact sports should be conducted before conclusions can be drawn about SRCs.

Likewise, neuroscientists, Sara Tremblay, Alvaro Pascual-Leone, & Hugo Théoret, reviewed studies analyzing the effects developed by physical activity and sports-related concussions on white matter, grey matter, neurochemistry and cortical excitability (See Appendix A).  After analyzing their data, they suggested that the effects of sports concussions can be confounded by the effects of exercise (Tremblay et al., 2018). These studies sufficiently described the immediate or short-term injuries caused SRCs, and they were also able to collect data and conclusions about the possible relationships between SRCs and the severely declining rate at which young parents are allowing their adolescents to participate in contact sports.  

Chronic Effects of Sports-Related Concussions

In 2012, Grant Iverson, Ruben Echemendia, Amanda LaMarre, Brian Brooks, and Michael Gaetz conducted a case study with the use of ImPACT testing to validate their hypothesis that the athletes with three or more concussions would perform poorly on the tests.  The researchers were able to analyze 786 athletes, who were separated into groups based on the number of concussions that they had suffered in their lifetimes. As the researchers had expected, the group of 26 athletes, aged between 17 and 22, who had the three or more traumatic brain injuries (mTBIs) (See Appendix A) had the worst test results out of the entire case study (Iverson et al., 2012).  Despite their findings, the data they collected was not strong enough to provide a definite conclusion that multiple concussions had consequential effects on the human brain.

The findings of Iverson et al. (2012) can be seen on a more impactful level in the research completed by Louis De Beaumont, Marc Beauchemin, Cory Beaulieu, and Paul Jolicoeur, all professors at the Departments of Psychology at the Universities of Montreal and Quebec.  The neuroscientists used error-related negativity (See Appendix A) to demonstrate that experiencing more than two concussions will most likely lead to short term memory loss only (De Beaumont et al., 2013). The researchers hypothesized that there was a weak link between concussions and lacking the ability to remember events that happened just minutes ago; however, they found that the link was actually quite strong.  Their data suggested to them that the neural mechanisms which work together to allow humans to have a working memory and to be attentive were significantly affected by multiple head injuries.

Various authors have used De Beaumont et al.’s (2013) research and conclusions as an impetus for their own studies.  For example, the Understanding Neurologic Injury and Traumatic Encephalopathy (UNITE) project is an organization with the goal of examining the neuropathology (See Appendix A) and clinical presentation of brain donors designated as “at risk” for the development of chronic traumatic encephalopathy (CTE) (See Appendix A) based on prior athletic exposure.  Over the course of 4 years, neurologists employed by the Miami University UNITE program “examined the nervous systems of 300 deceased subjects who had a history of repetitive head impacts sustained during participation in contact sports” (Mez, Solomon, & Daneshvar 2015). During the study, “clinical data was collected through medical record review and retrospective (See Appendix A) family interviews conducted by a behavioral neuropsychologist” (Mez, Solomon, & Daneshvar 2015).  The project’s managers were ultimately proven correct at the completion of the study because their inquiry demonstrated that the UNITE project could be a valuable part of the process for diagnosing collegiate-level athletes post-concussion. At the conclusion of their study; however, the neuropsychologists failed to come to a consensus on the most comprehensive manner to appropriately prevent CTE, mainly due to their inability to examine tau protein (See Appendix A) build-up in the human brain of a living athlete.   

Return-to-Play Program Specifics

Ruben Echemendia and Robert Cantu (2003) conducted a case study that attempted to show the benefits of using Return-to-Play programs (RTP) (See Appendix A) as an avenue of recovery for recently-concussed players.  In this research, the aforementioned neuropsychologists described the “emergence of neuropsychology in sports medicine, discussed the context in which RTP decisions are made and outlined factors that are important to RTP decisions”, but they failed to investigate how athletes benefit directly from participating in the RTP program (Echemendia & Cantu, 2003).  It was concluded at the completion of the case study, that neuropsychology did not have an exclusive role in determining when a player can resume physical activities, as seen in the image below (Echemendia & Cantu, 2003).

Note. Adapted from Echemendia, R., & Cantu, R. (2003). Return to Play following sports-related mild traumatic brain injury: The role for neuropsychology. Journal of Applied Neuropsychology, 10, 48-55.

Figure 1.1 This dynamic model for return to play demonstrates the intricate interplay between the abundant variables in an athlete’s life that contribute to an athlete’s participation in the return to play program.  

To build on Echemendia and Cantu’s (2003) previous research, Victoria Merritt and Peter Arnett (2014), professors in the Department of Psychology at Pennsylvania State University, used commonly-employed testing, such as ImPACT, as a representation of the RTP program, to prove that these tests could be used to predict the onset of post-concussion symptoms on the brain (Merritt & Arnett, 2014).  Two groups of participants were examined: non-concussed athletes athletes (N = 702) and athletes post-concussion (N = 55). Data was collected through the use of the Post-Concussion Symptoms Scale (PCSS) (See Appendix A). “A factor analysis was conducted on the participants’ baseline PCSS data to examine the baseline PCSS symptom clusters, demographic variables, and baseline neurocognitive variables as predictors of postconcussion PCSS total scores (i.e., low versus high symptom reporting following concussion)” (Merritt & Arnett, 2014).  The case study led them to the conclusion that, with the ability to accurately understand the general realm of the symptoms that the athlete would experience later in their lives, neurologists and physical therapists could better diagnose the severity of the athlete’s concussions immediately after a concussion is suffered.

In order to understand ATCs’ perceptions of the RTP program, Oliver Barney, Katherine Caldwell, Eric Crist, Mandy Lawton, Nicholas Miller, Jared Tunkel, and Justin Waters (2014) conducted a survey of the preferred concussion-recovery method among 200 NCAA Division III (See Appendix A) universities, which revealed variability in how the guidelines are being carried out at each institution.  Forty-nine percent of Division III ATCs stated that they used sub-optimal testing, meaning that they did use a mixture of neurocognitive and balance examinations to assess injured student-athletes. The most commonly selected tool for this exam was the ImPACT tool (see Appendix A), with roughly 66% of respondents indicating that they utilize ImPACT. Although the ImPACT tool is widely used in management of student-athletes with concussions, it does not include an assessment of balance (Barney et al., 2014).  Barney et al. (2014) suggested that disparity in the utilization of the NCAA concussion management guidelines could be as a result of the room for interpretation in these guidelines. While the NCAA identifies the essential components required to be used in the RTP protocol (See Appendix B), according to Barney et al. (2014), these components do not appear to have been incorporated to an adequate extent into the required concussion management guidelines.

Despite the groundbreaking results and conclusions that each of the aforementioned studies found, each has failed to investigate one aspect of the concussion recovery process: the athletes’ perceptions of the RTP program.  Therefore, the gap in this research is how the student-athletes perceive the RTP program as a whole. This study will explore the extent to which athletes who participate in contact sports, such as ice hockey and football, believe that the RTP procedure is a pertinent aspect of the concussion recovery process.  In conclusion, this study intends to collect data which answer the following research question: to what extent do the perceptions of the RTP program contrast between male and female high school students and athletic trainers in Suffolk County, New York?

Methods

Participants

Participants were (N = 40) 22 males and 18 females separated over four different strata: student-athletes in a North Shore, Long Island high school, ATCs, and coaches of contact sports in high school.  Compensation in the form of candy was provided to those with face-to-face contact, while others who were contacted via email were not compensated. All participants were located in Suffolk County, New York, with a population of 1,493,350 (50.7% female, 49.3% male) (U.S. Census Bureau).  In particular, 70.9% (N = 22) of the participants classified as high-school-aged student-athletes, while 29.1% of the sample were adults. Specifically, 12.9% (N = 4) were coaches of high-school contact sports and 16.2% (N = 5) were either ATCs associated with a high school on Long Island, private-practice ATCs or physical therapists.  Participation was voluntary; however, participants who had not suffered a concussion while playing a contact sport, such as ice hockey, football, lacrosse, etc., or helped treat one prior to completing the survey, were excluded, as the survey contained questions pertaining to the participant’s previous experiences with SRCs.

Procedure

This research study was best completed as a qualitative case study, meaning the research yielded “information that cannot be easily reduced to numbers” and typically involves the examination of the characteristics or previous experiences of the study’s participants (Leedy & Ormrod, 2016).  Qualitative research was necessary for this study, as the survey contained questions pertaining to the participants’ recollection of their previous experiences with treating or recovering from a SRC. This study also used a form of survey research, defined by Leedy & Ormrod (2016) as “research [that] involves acquiring information about one or more groups of peopleーperhaps about their characteristics, opinions, attitudes or previous experiencesーby asking them questions and tabulating their answers” (p. 141).  This type of research was useful because it allowed the participants to respond to several prompts about their beliefs about the efficacy of the RTP program and their participation in the RTP procedures. This study utilized proportional stratified sampling, meaning that there were different-sized samples from different types of samples, or strata (Leedy & Ormrod, 2016, p. 162). This was appropriate in this study specifically because the study examined three strataーathletes in high school, private-practice and school ATCs, and coaches of high school sportsーthat differed in size.  The ratio of athletes sampled to trainers was 3:1, while the ratio of trainers to coaches was 1:1 and the ratio of coaches to students was 1:3. The dependent variable of the study was the perceptions of the RTP program, while the independent variable was the different strata that were present in the study: student-athletes, high-school coaches, high-school ATCs and private practice ATCs. Both variables correlated directly with the research question because they outlined the two aspects of the inquiry that were studied and/or measured. The coaches who participated in this research study were first determined to be eligible to complete the survey only if they had coached a contact sport, like soccer, ice hockey, and football, at the high-school level.  Eligible coaches were then contacted via email and asked if they were willing to answer the survey questions. Participants were provided with an informed consent document, which outlined the goals of the research study and any potential risks, such as sadness or depression, that were associated with completing the survey. Asking participants to reflect on their past experiences with mild traumatic brain injuries put them at risk for developing negative emotional effects. Additionally, the email asked if the players whom they coached could also complete the survey ―depending upon whether the athlete had suffered a concussion― either during a practice or team meeting before or after school was in session, or during the Seminar / Study Hall period. This period of 1 hour, 20 minutes can be used in a variety of ways by each student.  In this case, the student used an average of 10 minutes of their time to complete the 13-item survey questionnaire on Google Forms in their homeroom or in Computer Lab A at a North Shore, Long Island High School. After all participants were finished answering the questionnaire, data was compiled and coded on a Microsoft Excel spreadsheet.

Instruments

Participants responded to the 13-item survey in a variety of ways (See Appendix C).  Ten of the 13 items contained multiple choice responses, two had areas for each participant to respond to the question in their own words and one question used a version of the Likert Scale.  The survey’s questions were directly derived from a study completed by Oliver Barney, Katherine Caldwell, Eric Crist, Mandy Lawton, Nicholas Miller, Jared Tunkel, and Justin Waters (2014), doctors of physical therapy from Utica College, who examined the perceptions of ATCs from over 200 Division III NCAA institutions on the usefulness of the RTP program.  The researcher decided to use survey research instead of a correlational analysis based upon the recommendations of Barney et al. (2014) in their inquiry, which stated that a correlational analysis would not be able to examine the entirety of the varying perspectives of ATCs or other strata, if further research was to be conducted. The question containing the Likert Scale asked the participants (Overall, how important do you feel the RTP program is in aiding athletes in their return to contact sports?), and prompted them to select a number from one to five.  One on the scale was labeled “Not important at all”, Two meant “Not vital to the athlete’s recovery”, Three was called “Unsure / No opinion”, Four meant “Important to the athlete’s recovery” and Five was labeled as “Extremely important / Should be a requirement”. Participants also answered a question which prompted them to select the type of training exercises that a concussed athlete should be examined for by an ATC. The participants were given the following choices to assess their knowledge of the RTP program: change in direction / elevation drills, physical strength, endurance drills, and unsure.  This question ultimately would examine the participant’s expertise in the testing that the RTP program uses to help athletes recover from concussions, by exploiting one of these side effects ―change in elevation and direction― to ensure that the player is almost completely symptom-free. In order to compile and analyze the data collected by the survey, all survey responses were gathered on a Microsoft Excel spreadsheet. This helped to establish similarities or connections between the responses and begin the coding portion of the data-analysis process. The survey was located on the Google application Google Forms and was accessed through the use of either the participants smartphones or the Dell computers located at the dissemination location (a North Shore, Long Island High School).  Microsoft Excel and Google Forms were both very reliable because all of the information on the survey and spreadsheet was password-protected, as were the smartphones and computers used in the dissemination process, which further exemplified the reliability of this study’s results.

Hypothesis & Assumptions

Prior to conducting this research study, the researcher had one hypothesis about the outcome of the study, which pertained to the responses the participants would provide from the survey.  This hypothesis was that all three strataーathletes, ATCs and coachesーwould respond positively when asked about their experiences with and opinions of the RTP procedures. This is a justified hypothesis because most teenagers and adults are likely to trust their neurologists and ATCs in the athlete’s recovery from a SRC due to the neurologists’ or ATCs’ expertise in treating concussions, but also due to the fact that the RTP process was developed by neurologists who conducted extensive research into concussions and how to best prevent the injuries caused by these head injuries.  

The researcher also assumed that the participants would answer the survey questionnaire truthfully and to the best of their ability, since the researcher believed the participants would want to contribute to the neurological field by answering a quick survey.  In addition, the researcher assumed that the results of their study would make a profound impact in the neurological and sports communities. This was a justifiable expectation, since concussions in sports and how to limit them has been at the forefront of debate in these two fields and this research might provide a different perspective: that of the athletes who are completing the stages of the RTP program, to aid in the evaluation of the efficacy of the RTP procedures.

Results

Figure 2.1 This graph shows the differences between student, ATC and coach responses to the 11th question of the study’s survey (see appendix C for complete survey). This question asked participants if they wanted to include any previous experiences suffering or treating a concussion and if the Return-to-Play program helped them in their recovery from the head injury.

The figure above is a graphical representation of student and adult beliefs toward the usefulness of RTP in treating a concussed athlete.  Individual short responses were coded by the researcher depending on whether they were positive ―assigned a one― or pessimistic views ―assigned a zero― of RTP.  Students (N = 21) had answers generally indicating a positive perception of the usefulness of the RTP procedures in helping concussed athletes. In comparison, ATCs (N = 5) had perspectives that RTP was helpful for concussed athletes, as 60 percent of the ATCs studied had positive responses to this question.  Similarly, coaches had an average answer which tended to be much more positive, indicating that they had positive opinions of RTP’s ability to aid in removing an athlete’s concussive symptoms.

Table 1

Participant Perceptions of the Importance of RTP

Strata
Mean (Average) Response
Standard Deviation (SD)
Student-athletes
4.381
.6287
Athletic Trainers (ATCs)
4.600
.5477
Coaches of High School, Contact Sports
4.500
.8165

Figure 2.2 This chart displays responses to the 13th question of the survey.  This question prompted this study’s participants to provide how important they felt the RTP protocol is in a concussed-athlete’s recovery from a head injury.  

Students responded with mainly positive opinions to this question in the survey.  The average answer from a student-athlete was 4.38, but responses were as high as five and as low as two.  Trainers and coaches responded almost unanimously, with all of the participants in these two strata providing answers of four or five to this part of the questionnaire.  Thirty-three percent of students responded with a five, indicating that they thought RTP should be a requirement in an athlete’s rehabilitation. Furthermore, 60 percent of trainers responded with a five, while 50 percent of coaches responded with a four, illustrating some disparity between the participants’ perceptions of the RTP procedures.

Table 2

Participant Opinions of the Duration of RTP

Strata
Mean (Average) Response
Standard Deviation (SD)
Student-athletes
.78889
.4915
Athletic Trainers (ATCs)
1.000
.0001
Coaches of High School, Contact Sports
1.000
.0001

Figure 2.3 This table demonstrates the average responses for student-athletes, coaches and ATCs to the question, “Anything you would like to include about your beliefs that RTP helps players recover from a concussion and play again in a quick manner?”

Student response rates continued to more be consistent on this question than any other question, especially when compared to the answers of the trainers and coaches who participated in this study.  Students, coaches and ATCs all responded in favor of RTP being useful in aiding athletes recover from head injuries quickly. Answers were coded with a one if the answer was positive and a zero if the response contained a negative opinion of RTP.  As a result, students had an average response of .78889, suggesting positive perceptions of the RTP protocol. Coaches and ATCs had unanimous responses, which also contained beneficial perspectives on the use of the RTP procedures in an athlete’s rehabilitation.  

Discussion and Conclusions

Analysis

The initial goal of this research study was to ultimately ascertain if student-athlete attitudes toward the RTP program were in any way similar or different to the perspectives of ATCs and coaches of high school, contact sports.  Current literature exists on the importance of utilizing the RTP procedures in a concussed athlete’s recovery from a mild traumatic brain injury, but limited research studies have investigated previously-concussed athletes’ opinions about the efficacy of RTP in their rehabilitation.  To answer the research question posed in this study, the researcher first had to suggest that the RTP protocol was a prominent aspect of the concussion-recovery process. Next, the researcher needed to find participants that had either completed RTP or helped an athlete heal from an mTBI by using RTP.  Finally, in order to decisively attain their research objective, the researcher had to propose that there were substantial corroborating and/or contradicting views of RTP among student-athletes, coaches and trainers.

The results from Figures 2.1 and 2.3 were contradictory to what the researcher had hypothesized prior to conducting research.  Figures 2.1 and 2.3 demonstrated the perceptions of each strata of RTP’s ability to allow a concussed athlete to heal completely from their concussive symptoms in a quick manner.  It was expected that the trainers and coaches would have more forward-looking views of RTP, and athletes would have more negative thoughts about this program because of the strenuous exercises the athletes are asked to complete to test their healing progression.  However, after analyzing the data, athletes had even more positive perceptions of RTP than the trainers and coaches. These unanticipated results could be accounted for by the athletes possibly recovering completely from their mTBI despite having to perform tasking workouts while participating in RTP.  This study’s findings about the ATCs’ perceptions of RTP conflict with Barney et al.’s (2014) findings that ATCs tended to use RTP because the program provided athletes with the highest chances of full recovery from a concussion. The difference between the results in the two studies is seen in the fact that Barney et al.’s (2014) group of ATCs had extremely positive perspectives about RTP, while this study’s sample of ATCs only had the least positive views of RTP out of the three strata sampled. Discrepancies in perceptions could be justified by the possible presence of partiality of trainers in either of the studies, especially if their responses to the questionnaires could affect their job status.  Thus, it cannot be said currently whether all trainers or students agree that the RTP program is the most beneficial approach to the concussion-recovery system.

Figure 2.2 struck at the heart of this study’s purpose, by explicitly asking all participants to provide their opinion as to whether RTP was essential for an athlete post-concussion.  The results shown in this chart demonstrated that the wide majority of the sample believed that RTP was a crucial aspect of an athlete’s recovery. This was contradictory to what the researcher had hypothesized prior to conducting this research study, as the researcher believed that the student-athletes would have had negative perceptions of RTP.  This was based off Echemendia and Cantu (2003)’s inquiry, which concluded that student-athletes would oppose using RTP because this program requires that concussed athletes be sidelined from physical activity for a longer duration of time than athletes who decided to use rest as a way to stave off any concussive symptoms. With the average response from each strata being at least a four, it can be deduced that both medical professionals and the general public, represented by the athletes and coaches in this particular study, believe that the RTP protocol is a useful component in current concussion-rehabilitation methods.  

Moreover, this conclusion correlates to the findings of both Barney et al. (2014) and Echemendia and Cantu (2003).  In this study and Barney et al.’s (2014) research, the ATCs that were surveyed reported positive feedback on the usefulness of RTP post-concussion.  This research corroborates Echemendia and Cantu (2003), who investigated RTP and concluded that it was effective in removing athlete’s concussive injuries, but Echemendia and Cantu (2003) went further to conclude that RTP would be looked upon in a negative light by athletes because RTP could potentially cause some concussive symptoms to redevelop during the six-step process.  Here, this research differs from Echemendia and Cantu (2003) because the strata of student-athletes in this sample had positive perceptions of RTP’s efficacy. The reason for this controversy could be that this study’s sample of athletes did not experience the redevelopment of any signs of concussive injuries or that Echemendia and Cantu (2003) could have possibly made a conclusion that only pertains to athletes with major concussions, when this study focused on players who had suffered a concussion, regardless of its severity.  

Limitations and Future Research

The findings of this study must be seen in light of some limitations.  The primary limitation surrounding the study lies within the cohort’s size and location.  Considering that only 35 participants were studied and that the study was concentrated in only one part of New York―Suffolk County, New York, specifically―the amount of data the researcher was able to codify and analyze was not lengthy.  Perhaps a study including a sample size of high-school and college students in the entirety of New York State would suggest a better correlation between the use of the RTP program and the success of previously-concussed athletes returning to contact sports symptom-free.  Another prominent limitation in this study was the presence of self-reported data, specifically selective memory and exaggeration. Because each participant was asked to reflect and provide previous experiences with SRCs, it was a possibility that the participants did not accurately depict the events that occurred related to suffering or treating a concussion. This could be due to the chance of participants having suffered amnesia from their head injury.  Perhaps a study, like the one conducted by Oliver Barney (2014) and his team of physical therapists at Utica College, which implemented a criteria that each participant must have suffered or treated a concussion within the year leading up to the start of the study, would help prevent any embellished or unreliable qualitative data from being collected.

Implications

This research has extensive ramifications in both the neurological field of study and the sports community.  Although further research must certainly be conducted to see if this study’s findings and conclusions are indeed true, this inquiry’s ability to investigate the perceptions of four different strata of the RTP procedures cannot be overlooked.  Concluding that student-athletes believe that RTP is efficient and useful in a concussed-athlete’s recovery is crucial because the effects of SRCs can be monitored most effectively while an athlete is resting and/or recovering in the RTP setting.  Athletes’ positive perceptions of the RTP program could cause more athletes who suffer a mild traumatic brain injury while playing contact sports, like ice hockey, lacrosse or football, to utilize RTP while recovering, which would limit both the persistence of concussive symptoms on the athlete’s brain and the potential for the occurence of the possibly-fatal Second Impact Syndrome exponentially.  Providing the neurological and neuropsychological fields with athletes’ perceptions of the RTP procedures is also immensely important. Because of this research, neurologists and neuropsychologists could conduct a thorough review of the six-step RTP protocol and possibly come to one of two conclusions. The first being that the program is effective the way it is currently. The second judgment could be that this vital aspect of an athlete’s recovery from a concussion could potentially be reconstructed (i.e. removing any unnecessary exercises and/or examinations in the RTP protocol) to be even more successful with healing concussed athletes fully.  Finally, this study’s findings could lead to additional research on the RTP program, which has the potential to solve the issue of declining participation in contact sports in the United States, due to the recent spike in the amount of SRCs suffered each year. In other words, with more studies that portray concussions as injuries that can be recovered from with the use of RTP, more parents could allow their young children start playing physical sports, mainly because of the recovery programs in place in case of injury. 

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Appendix A: Glossary

Chronic traumatic encephalopathy (CTE): “...a progressive neurological disease that is found especially in athletes who have experienced repetitive, mild injury to the brain and that is characterized by short-term memory loss, concentration deficits, confusion, depression, behavioral and personality changes, speech and gait abnormalities, parkinsonism, and dementia.” (Mez, Solomon, & Daneshvar 2015)

Cortical excitability: “...the level of neuronal excitability (excited or inhibited) either directly by controlling flow of ions through ion channels or through a complex cascade of intracellular interactions via secondary messengers; excitation is mainly facilitated by the action of glutamate on N-methyl-d-aspartate (NMDA), and non-NMDA receptors, while inhibition is mainly mediated by the action of gamma-aminobutyric acid (GABA) on GABAA and GABAB receptors.” (Tremblay et al., 2018)

Error-related negativity (ERN): “A component of an electrical activity in the brain as measured through electroencephalography and time-locked to an external event or a response.” (De Beaumont et al., 2013)

Grey matter: “A neural tissue especially of the brain and spinal cord that contains nerve-cell bodies as well as nerve fibers.” (Tremblay et al., 2018)

ImPACT: “A computerized neurocognitive test designed to assess an athlete’s concussive symptoms.” (Barney et al., 2014)

Mild traumatic brain injury (mTBI): “An injury that results from the occurrence of a concussion caused by a head trauma.” (Theriault et al., 2011)

National Collegiate Athletic Association (NCAA): “The national governing body that regulates all male and female Division I and III sports in all colleges and universities located in the United States of America.” (Barney et al., 2014)

Neurochemistry: “The study of the chemical makeup and activities of nervous tissue.” (Saunders & Harbaugh, 1984)

Neuropathology: “The study of the essential nature of diseases located in the nervous system and especially of the structural and functional changes produced by them.” (Saunders & Harbaugh, 1984)

Neurologist: “A physician skilled in the diagnosis and treatment of disease of the nervous system.” (Saunders & Harbaugh, 1984)

Neuropsychologist: “A physician specialized in a science concerned with the integration of psychological observations on behavior and the mind with neurological observations on the brain and nervous system.” (Saunders & Harbaugh, 1984)

Neuropsychology: “A science concerned with the integration of psychological observations on behavior and the mind with neurological observations on the brain and nervous system.” (Saunders & Harbaugh, 1984)

Post-Concussion Symptoms Scale (PCSS): “Scale which allows the concussed athlete to report his/her symptoms from mild to severe.” (Merritt & Arnett, 2014)

Retrospective: based on memory

Return-to-Play (RTP): “A main form of concussion recovery; used to help athletes participate in contact sports post-concussion free of all concussion symptoms.” (Echemendia & Cantu, 2003)

Sports-related concussion (SRC): “A form of a mild traumatic brain injury that is suffered while an athlete is playing sports; mainly caused by an outside trauma or force.” (Theriault et al., 2011)

Sustained Posterior Contralateral Negativity (SPCN): “Associated with the drawing on visual short-term memory (vSTM) or working memory representations required for further cognitive operations with the stimulus material.” (Theriault et al., 2011)

Tau: “A protein that binds to and regulates the assembly and stability of neuronal microtubules and that is found in an abnormal form as the major component of neurofibrillary tangles.” (Mez, Solomon, & Daneshvar 2015)

White matter: “A neural tissue especially of the brain and spinal cord that consists largely of myelinated nerve fibers bundled into tracts and typically underlies the cortical gray matter.” (Tremblay et al., 2018)

Appendix B: Return-to-Play Protocol

6-Step Return-to-Play Progression

If an athlete’s symptoms re-develop or new concussive symptoms affect the athlete during the 6-step procedure, the athlete must wait until they are symptom-free for 24 hours.  After they are able to participate in the protocol again, they must start at the step which caused concussive symptoms to develop.

Step 1: Athlete returns to school

Athlete must rest for 2-3 days after they suffer a concussion, then they may be examined by a neurologist, who will allow the athlete to return to school, only if the athlete is symptom-free.

Step 2: Light aerobic activity

Athlete may complete 5 to 10 minutes of light aerobics, meaning walking, running or using the elliptical.  This step is used to mainly re-introduce increasing the athlete’s heart rate.

Step 3: Moderate aerobic activity

Athlete may continue to increase their heart rate with aerobics mentioned in previous step.  Athlete must now be able to walk, run, or use elliptical for 15-20 minutes continuously. The athlete may also begin to complete light weightlifting for a short period of time (10 to 15 minutes).

Step 4: Difficult, non-contact activity

Athlete may participate in strenuous, non-contact physical activity.  These activities include sprinting, intense use of the elliptical, sudden change in direction and elevation drills, and some sport-specific training exercises.  

Step 5: Practice & full contact

Athlete is allowed to return to practicing with full contact in a controlled environment, meaning their coach is consistently watching the athlete complete team drills and asking the player if they have any symptoms.

Step 6: Full participation

Athlete may return to playing in competitions against other opponents.

Appendix C: Survey

Consent * Required

1.  I understand that my participation in taking this survey is voluntary and that I may stop at any time for any reason and may skip any questions that I do not feel comfortable answering.  I have read the consent form and agree to its terms and conditions.  I understand that all information is anonymous and that all data will be deleted on completion of the study.  Pseudonyms will be used for any identifying information, and participants may view my results upon completion of the study (contact project advisers found on Informed Consent Document).  * Mark only one oval.

◻️Yes, I agree.  

◻️No, I do not agree.

Students and Adults' Perceptions of the Usefulness of the Return-to-Play Program

Thank you for participating in my study.  I hope you had as much fun attending as I did organizing it.  

Please fill this quick survey and let me know your thoughts (your answers will be anonymous).

2.  Please indicate your gender: Mark only one oval.  

◻️Female

◻️Male

◻️Prefer not to say

3.  Please indicate if you are any of the following: Check all that apply.  

◻️High School-aged Student-athlete

◻️Coach of High School Sport

◻️Physical Activity High School Athletic Trainer

◻️Private Practice Athletic Trainer or Physical Therapist

4.  Have you ever taken a specialist-directed examination prior to the start of a new sports season? Mark only one oval.  

◻️Yes

◻️No

◻️Maybe

5.  Have you ever taken the same exam after you suffered a concussion in that same season? Mark only one oval.  

◻️Yes

◻️No

◻️Maybe

6.  Were you assessed for concussive symptoms before taking a test, such as the ImPACT Examination? Mark only one oval.  

◻️Yes

◻️No

◻️Maybe

7.  Indicate which of the following you believe should be included in a concussion-recovery process, in a stage of physical exertion: (Check all that apply).  

◻️Push-ups

◻️Knee Bends

◻️Jumping Jacks

◻️30 or 40-Yard Sprints

◻️Agility and Sudden Change in Direction Drills

◻️Sit-ups

◻️Unsure

8.  Which of the following do you believe to be the most important aspect of the Return-to-Play program that an athletic trainer should examine a recovering athlete for? Mark only one oval.  ◻️Change in Direction / Elevation Drills

◻️Physical Strength

◻️Endurance Drills (running the mile, etc.)

◻️Unsure

9.  During a concussion-recovery process, after a stage of physical exertion, do you believe a symptom check immediately after by a neurologist or athletic trainer should be required? Mark only one oval.  

◻️Yes

◻️No

10.  Indicate which of the following you believe to be the most impactful injuries caused by a concussion: (Check all that apply).  

◻️Sensitivity to Light

◻️Sensitivity to Noise

◻️Irritability

◻️Sadness / Depression

◻️Numbness or Tingling

◻️Feeling Slowed Down

◻️Feeling Mentally "Foggy"

◻️Difficulty Remembering / Concentrating

◻️Visual Issues

◻️Headache

◻️Nausea

11.  Anything you would like to include about your experiences suffering and recovering from a concussion if you have suffered one?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12.  Anything you would like to include about your beliefs that RTP helps players recover from a concussion and play again in a quick manner?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  

13.  Overall, how important do you feel the Return-to-Play program is in aiding athletes in their return to contact sports? Mark only one oval.  

◻️1 - Not important at all

◻️2 - Not vital in the athlete's recovery

◻️3 - Unsure / No opinion

◻️4 - Important to the athlete's recovery

◻️5 - Extremely Important / Should be a requirement

Appendix D: Informed Consent Document

AP Research

Informed Consent to Participate in Research

Study title:  The Impact of Students’ Perceptions of the Return-to-Play Program (RTP) on the Students’ Possibilities of Utilizing the RTP Program

Researcher[s]: [AP Capstone: Research Student]

I am inviting you to participate in a research study.  Participation is completely voluntary. If you agree to participate, you can always change your mind and withdraw.  There are no negative consequences, whatever you decide.

What is the purpose of this study?

I want to understand if the programs which help male student-athletes heal/recover from head injuries are able to prevent the long-term effects of these head injuries.   

What will I do?

This survey will ask questions about the sport(s) you were playing when you suffered a concussion, the symptoms you felt immediately after and two to three days after you suffered the concussion, and the steps that you took to recover from your concussion (i.e.  rest, participating in Return-to-Play program, etc.).

Risks

Some questions may be very personal or upsetting.  You can skip any questions you don’t want to answer, or stop the survey entirely.
Online data being hacked or intercepted: This is a risk you experience any time you provide information online.  I am using a secure system to collect this data. This secure system is the Google application “Google Drive”, and it will serve two purposes: 1) to store all data in one place and 2) to keep all data in a password-protected location.   
Breach of confidentiality: There is a chance your data could be seen by someone who shouldn’t have access to it.  I am minimizing this risk in the following ways:
Data is anonymous.  
I’ll remove all identifiers.
I’ll store all electronic data on a password-protected, encrypted computer.  
Some questions may bring up some upsetting memories about the time that you suffered a concussion while playing sports.  You have the ability to leave these questions blank if you wouldn’t like to answer.

Possible benefits:

Individual Benefits
The feeling that you have taken part in a survey that will help the general public in choosing the best recovery program for athletes that have recently suffered a concussion while playing a contact sport.  
Societal Benefits
This study will contribute to larger studies that are attempting to prevent concussions from occurring in contact sports altogether.  
Neurologists and physical therapists will have more knowledge of the usefulness of Return-to-Play programs after the completion of this study.   
Therefore, neurologists and physical therapists will be able to make the decision that is most beneficial for the athlete, in terms of what steps need to be taken in order to allow athletes to heal fully from a sports-related concussion.   

Estimated number of participants: Between 25 and 50 male and female students, athletic trainers and coaches will be surveyed in Suffolk County.

How long will it take? This survey will take at most 20 minutes to complete.

Costs: None

Compensation: Candy

Confidentiality and Data Security- NOT APPLICABLE

Where will data be stored? All data will be stored on my own password-protected Google Drive account after the surveys are completed on Google Forms.   

How long will it be kept? Data will be kept until June 2019, when this study’s data will then be destroyed.   

Who can see my data?

I (the researcher) will have access to coded data (names removed and labeled with a study ID).  This is so I can analyze the data and conduct the study.
The Institutional Review Board (IRB) at.  This is to ensure we’re following laws and ethical guidelines.
The AP College Board.  The results will be de-identified (no names, birthdate, address, etc.).  If I quote you, I’ll use pseudonyms (fake names).
I may share our findings in publications or presentations.  If I do, the results will be de-identified (no names, birthdate, address, etc.).  If I quote you, I’ll use pseudonyms (fake names).

This study has a Certificate of Confidentiality

To help us protect your privacy, I have a Certificate of Confidentiality from the National Institutes of Health (NIH).  

Contact information:

For questions about the research, complaints, or problems: Contact Teachers/Project Directors.

Please print or save this screen if you want to be able to access the information later.

IRB Approval Date:

Agreement to Participate

If you meet the eligibility criteria below and would like to participate in this study, begin the survey.  Remember, your participation is completely voluntary, and you’re free to withdraw at any time.

Parental consent
Male
Age 14-18
Suffered at least one concussion while playing sports in your lifetime

Consent:

I understand that my participation in taking this survey is voluntary and that I may stop at any time for any reason.  I have read the consent form (see right) and agree to its terms and conditions. I understand that all information is anonymous and that all data will be deleted on completion of the study.  Pseudonyms will be used for any identifying information, and participants may view my results upon completion of the study (contact project directors found in Informed Consent Document).

Appendix E: Parent Consent Document

AP Capstone: AP Research

Parent Consent Form

This High School is currently offering the AP Capstone: AP Research course in which students plan and conduct their own research study.   This study requires that the researcher gives out surveys to other students in the school building.

Students will be asked to fill out a survey that will only take them a few minutes to complete.   This survey will not be done during class instructional time. The survey will focus on the following topic:

Your child will incur little to no risk for participating in any of the above survey.  The only potential risk is that some students might find certain questions to be sensitive.  Moreover, the survey have been designed to protect your child’s privacy. Students will not put their names on the survey nor will any of their personal or confidential information be collected in the survey.  Also, the school and student will never be mentioned by name in a report of the results. All names will be redacted from the research and no identifiable information or data will appear in the paper or the results.   

This survey is completely voluntary.  No action will be taken against your child, you, or the school if your child does not take the survey.   Students may skip any questions they do not wish to answer. In addition, students may stop taking the survey at any point without penalty.  If you would like to see the survey, copies are available by contacting the supervising teachers.

Complete the section below and return it to the school within 15 days in order to grant your child permission to take part in this survey.  Failure to complete the section below and return it to to the school within 15 days will be deemed as nonconsent and your child will not participate in the survey process.

Please complete this section of the form only if you are allowing your child to participate in the survey mentioned above.  

Student’s Name: ____________________________________________

Grade: _______

Parent/Guardian’s Name: ____________________________________

Parent/Guardian’s Signature: _________________________________

Date: ___________

Appendix F: IRB Approval

AP Capstone: AP Research

Project Title: The Impact of Students’ Perceptions of the Return-to-Play Program (RTP) on the Students’ Possibilities of Utilizing the RTP program

Project Question: To what extent do the perceptions of the Return-to-Play program contrast among male and female high school students in Suffolk County, New York? How do these perceptions affect the students’ participation in the Return-to-Play procedures if they suffer a concussion?

Project Status: Approved

Project Start and End Dates: September 2018 - April 2019

Where will the work be done? At school and at home

Project Type: Student Research (under faculty direction)

Class: AP Research

Research is a systematic investigation including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge.

Pilot studies are research, and you must submit IRB applications for them.

A human subject is defined as a living individual about whom an investigator conducting research obtains (1) data through intervention or interaction with the individual, or (2) identifiable private information about whom includes a subject's opinion on a given topic.

1.Is this study Human Subject Research?                        

YES
NO
 

2.   Will you expose subjects to any mechanical or electrical equipment? (If you will be using a personal computer, iPhone, iPad, or similar personal use device, a “safety check” is not required.)     

YES
NO  
 

If yes, document how such a safety equipment check can be verified by your respective administrator/teacher.

3.  Do you plan to disseminate the results of this research through professional/scientific conference presentations or publications to expand academic knowledge?          

YES
NO

4.  Does this project or study involve collection of data that identifies individuals (e.g., cohort databases included SSN# Data on individuals, surveys, or interviews identifiable by name or student number etc.)?

YES
NO
 

5.  Will data identifiable by individuals be shared with anyone (such as in a performance report for a funding source, conference presentations, published articles and reports, etc.)?

YES
NO
 

6.  Are the participants being offered one or more of the incentives to participate (such as money, extra credit for the class, etc.)?

YES
NO

If yes, list the incentive(s) here:

-Candy

7.  Is participation in this project or study voluntary for the individuals participating in the program or study?

YES
NO
 

8.  Will participants be fully informed about the benefits and any risks?

YES
NO

9.  Will participants be videotaped during the project or study?

YES
NO
 

10.  Will participants' privacy and personal information be protected?

YES
NO

If yes, briefly explain how privacy information will be protected.

The survey will be completely anonymous.  Therefore, the participants’ names and/or student ID numbers will not be recorded before the survey has been conducted.   I will only be recording the answers to the questions that I provide to the participants.

11.  Will participants be debriefed following completion of the project or study?

YES
NO
 

12.  Will participants, prior to the project, indicate informed consent to participate by completing and signing a written form?

YES
NO

If no, briefly explain how you will obtain consent from participants.

13.  Sample consent is included?

YES
NO
 

14.  Does the funding source have any potential for financial or professional benefit from the outcome for the study or project?

YES
NO

If yes, please explain.  

15.  Are data sources clearly identified (such as interviews, survey, existing project data such as services received, reports, grades, existing school records, focus group, etc.)?

YES
NO

16.  Sample data collection method is included?

YES
NO

Check all that apply and estimate total number of individual participants in each relevant category about whom you will be collecting data on for your project:

High school students                                         Number: 25
General public                                                   Number: __
Faculty                                                               Number: __
Children and Youth under 18                             Number: 25
 

1.   Describe Project and Purpose:

This research project will endeavor to understand the benefits of the use of Return-to-Play programs on the prevention of permanent brain damage that is caused by sports-related concussions.   The overarching purpose of this study is to provide neurologists with the best method of aiding athletes in their recovery and return to physical activities post-concussion.

2.  Methodology:

A.  Provide a brief description of the purpose of the proposed research in nontechnical language that could be understood by an educated person who is not a scholar in your field.      

The purpose of this research process is to find best way to help sports participants efficiently and completely heal from a head injury that they may have sustained.   Through the evaluation of the effectiveness of one of the procedures that can be used to overcome the trauma that is provoked by a sports-related concussion, athletes, neurologists and certified athletic trainers can more easily choose the best way for their specific patient to recover post-concussion.        

B.  Summarize below the procedures you will use with the subjects.  Please include all research procedures, e.g., how the psychological or physiological intervention will be conducted, how you will collect the data, how long the procedures will take the subjects to complete, etc.

This in-depth research study will take about 4-6 weeks to complete, due to the extensive data collection and analysis that is required for this project.  Data collection will be conducted through interviews, as well as the completion of a survey that will be administered to all participants in this examination.   Participants will have the option of either completing the survey on Google Forms or answering similar questions to the survey in a short interview. The participants’ personal information will be protected, as they will not be required to state their name, age or any descriptive characteristics that may lead to their identification.   While collecting data, I will assign a number to each of the part-takers, for the sole purpose of helping with data analysis (classification of subjects’ answers, creating data tables, charts, graphs, etc.)

C.  Indicate the method of data collection you will use.  (Check all applicable.)

Reviewing files or records       
Observations       
Test        
Treatment   
Interview
Questionnaire/Survey   
Task      
Other: Explain      

D.  Please indicate which type of design best describes your study.   (Check all applicable.)

Qualitative research methods           
Quantitative research methods
A correlational design                   
Mixed design                       
An experimental design    
Other: Explain:          

3.  Voluntary Participation:

How will you identify and contact potential participants?
In order to obtain participants for my research, I will be gathering large groups of athletes and asking the simple question of “Have any of you ever suffered a sports-related concussion? Those athletes that answer “yes” will be used to make up the subject group of my study and they will then be further separated into two groups: 1) those who have received Return-to-Play treatment and 2) those who have not.  Finally, the two groups will be asked to answer the interview or survey questions.

4.  Confidentiality of Data and Privacy Protection:

Explain the steps you will take to safeguard the participants' right to confidentiality if you have collected any personal identifying indicators on paper and pencil or on any digital web-based platform.
When I am collecting the data for my study, I will not be using any names, ages or characteristics of my participants for my data.  

How will you collect and store this personal information? Who will have access to it?
Although no identifying indicators will be recorded in the interview or ion the survey, all handwritten recordings will be kept in a lockbox and I will be the only one with the key to this box.  The results of the survey will be kept in a password-protected computer and the participants’ answers will be coded to prevent any possible identification after this research endeavor has been completed.   

How will the data be coded if it involves an audio/video recording? How will you keep  
            the information collected confidential? When will you ultimately destroy the data?

Audio and video recordings will not be taken.  I will keep handwritten data from the interviews that I conduct in a lockbox and all Google Forms surveys will be kept in a Google Sheets document on a password-protected computer.   The data that I will collect will be destroyed in June 2019.

5.  Informed Consent:

Please attach copy of informed consent document
Informed Consent Document

6.  Risks to Participants:     

    A. What risks/discomforts (e.g., physical, psychological, social, legal) do you anticipate could occur for participants?

The questions asked in my survey could bring up undesirable memories for the athletes about their concussion and the events leading up to the head injury.  Unfortunately, a major impact that concussions can trigger is short periods of amnesia, meaning the athlete loses memory before or immediately after the head impact.  Therefore, some of the athletes taking the survey may be unable to recount some of the events that caused the head injury and the steps that they took to recover from the concussion, prior to returning to physical activities.   

7.  Benefits:

What benefits do you anticipate for the participants themselves, society, and human/scientific knowledge?
The participants will not receive a tremendous amount of benefit from taking the survey because the concussions they have already suffered have already impacted their brains in a way that cannot be combatted or reversed.   However, at the conclusion of the survey, they may feel that they have made a significant contribution to the field of neurology and to public knowledge because the participants would then have contributed to evaluating the usefulness of Return-to-Play programs in helping athletes heal from short and long-term concussive injuries.  My survey’s results can potentially aid in the process of neurologists and physical therapists choosing the best procedure for post-concussion recovery, which benefits brain specialists, athletic trainers and athletes. These groups of people would benefit from my research because the decision to have the athlete participate in Return-to-Play protocol would be easier to make on the doctor or trainer’s part.  In this way, the athlete would have the confidence that they are receiving the best treatment possible to withstand the chronic injuries that are generated by sports-related concussions.

Appendix G: National Institutes of Health IRB Certificate of Completion