An estimated 300,000 sport-related concussions occur annually in the United States, with high school football players suffering more than 64,000 of those injuries (4, 12, 29). These are the known cases. Thousands more are believed to go unreported (5,16, 29). A concussion is defined as, "any transient neurological dysfunction resulting from a biomechanical force that may of may not result in a loss of consciousness" (8, p. 228). Unlike a cut, a scrape, or a broken leg, concussive injuries are rarely visually obvious. What makes concussive injuries even more complicated is the fact that concussion is a functional injury, not a structural one, meaning it will affect neurocognitive performance but not necessarily show up on MRI or CT scans (5,6,31). This could contribute to the lack of concussion diagnosis or to the belief that concussion does not necessitate conservative treatment if structural damage is not found. In 1990, Dr. M. Goldstein (9) referred to concussion as "a silent epidemic" (p. 327). Unfortunately, nearly two decades later, Goldstein's warning still sends shockwaves, as young athletes die from sport-induced concussions (1,13,25). Leading experts agree that high school athletes have a significantly greater risk of sustaining a concussion, and that those concussions take longer to heal when compared with concussions sustained by college-aged athletes (6,7). There are many potential reasons for this, but most researchers agree that the younger brain is more vulnerable because it is not fully developed (11,17). Furthermore, many concussions sustained by younger athletes go unreported because youth sport coaches, leaders, parents and even athletes themselves do not fully understand what concussion is or that it has occurred (6,16). Experts agree, even so-called "bell ringers" and "dings" require medical attention and should be considered concussive injuries (17,31). When such momentary states of disorientation or dizziness are ignored, an additional threat is posed in the form of Second Impact Syndrome, or SIS (1,13,22). SIS may occur when an athlete sustains a second concussion before the symptoms of the first have healed (1). Though rare, SIS is characterized by rapid swelling of the brain and may be fatal (2). SIS is most often associated with adolescent athletes, perhaps because of the sensitivity of their developing brains, and because the seriousness of the first concussion is often overlooked (1,5,13,22,28).
While the national spotlight illuminates instances of deaths that occur from sport-related concussion, there still remains the need to educate sport leaders on ways to protect the athletes who compete (21). The Centers for Disease Control and Prevention (3) offer a free toolkit, Heads Up: Concussion in High School Sports that is available to coaches at no charge. In addition, the National Athletic Trainers' Association (NATA) and its Appropriate Medical Care for Secondary School-Aged Athletes Task Force (AMCSSAA) have made several recommendations (11). Among them are that every high school in the United States develop and implement a comprehensive athletic health care administrative system. Athletic trainers and physicians are critical components of that system (11,16).
Recognizing a lack of athletic trainers in Idaho's secondary school setting and especially in the rural school environment, a study was conducted in 2006 with the dual purpose of examining the Idaho high school football coaches' general understanding of concussion, and determining whether or not those coaches were consistent with experts' recommendations when it came to managing concussion and determining the appropriate time for return to play following concussion. The findings make clearer the need for proper concussion management in high schools, including the need for athletic trainers and continuing education for coaches. Understanding the characteristics of concussion and recognizing the unavailability of athletic trainers, the following research questions guided this investigation: