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Article

Education and Awareness of Sports Concussion Detection and Management in Quadball: A Cross-Sectional Study

by
Som Singh
1,2,*,
Kiera Borthwick
3,
Rebecca Martin
2,
Demetrius Collins
2 and
Christopher Shaw
1
1
School of Medicine, University of Missouri Kansas City, Kansas City, MO 64108, USA
2
Department of Risk Management, US Quadball, New York, NY 10033, USA
3
School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
*
Author to whom correspondence should be addressed.
Emerg. Care Med. 2025, 2(2), 25; https://doi.org/10.3390/ecm2020025
Submission received: 13 December 2024 / Revised: 26 February 2025 / Accepted: 26 February 2025 / Published: 8 May 2025
Browse Figures
Versions Notes

Abstract

:
Background: Concussion education for athletes can improve long-term outcomes in injury prevention. As a contact sport, Quadball has seen tremendous growth in its player population over the past decade. However, there is a paucity of understanding of sports injury epidemiology in these sports compared to other contact sports in the world. The aim of this study is to describe the attitude, knowledge, and awareness of concussions among Quadball players in the United States. Methods: This study implemented a cross-sectional methodology. Specifically, a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) was introduced to Quadball participants to address the primary aim of this study. Results: A total of 237 Quadball players participated in this study. In this cohort, 57.8% of participants reported having some form of prior concussion training or education. A cumulative 77.0% accuracy of concussion knowledge index questions was found among participants. Conclusions: The findings of this study indicate that the knowledge of sports concussions in Quadball may be greater than or comparable to that of other contact sports in the United States.

1. Introduction

The ramifications of a concussion can affect multiple aspects of an individual’s quality of life, both acutely and long-term. Recently, this type of traumatic brain injury has gained a tremendous allocation of attention and resources toward improving detection, diagnosis, prevention, and management [1,2,3]. Among athletes, the nature of contact sports has made it imperative to reduce concussions and improve management capabilities, given the potential for devastating long-term effects on cognitive and physical function. Moreover, it is essential to provide athletes, coaches, and sports industry professionals with a comprehensive education regarding concussions. Education and health literacy are well established to contribute towards medical outcomes [4]. Specifically, poor health literacy and education are associated with worse health outcomes [5,6]. Regarding sports concussions, an educational aim is to ensure athletes develop competency in recognizing the signs and symptoms of a concussion, in addition to the importance of reporting these signs and symptoms and seeking appropriate medical care [7,8,9,10]. In addition to the initial injury, the underreporting of concussions can also lead to players being more prone to experiencing future concussions [11]. Among sports that have a risk of concussion, Quadball is a full-contact sport that is rapidly gaining popularity and recognition in the United States [12]. As this sport’s population continues to grow, it remains imperative to assess the attitudes and awareness of concussion symptomology and severity in this sport [12,13,14,15]. Therefore, the aim of this study is to describe the climate of attitudes and knowledge regarding concussions among Quadball participants through a cross-sectional methodology.

2. Materials and Methods

2.1. Participants

This was a nationwide cross-sectional study across active US Quadball members from the 2021 season. The Institutional Review Board by the University of Missouri Kansas City School of Medicine determined this study to be exempt (2023581), and permission was granted by the US Quadball Office of the Executive Director to conduct this study. Inclusion criteria for participants required them to be registered members during the 2020–2021 playing season of US Quadball.

2.2. Procedures

This study utilized a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) to assess the attitudes and knowledge of concussions among the study population [16,17]. This survey tool has been demonstrated to be reliable in observing knowledge and attitudes regarding concussions in sports medicine [18,19,20,21,22,23]. In accordance with the authors’ literature review of RoCKAS, a modified version of the Concussion Knowledge Index (CKI) and Concussion Attitude Index (CAI) question sets were implemented in this study (e.g., modified CKI, modified CAI). To the best of our knowledge, this modified version of the CAI and CKI has not been previously implemented in prior studies. Additionally, the demographic data were collected regarding the study participants’ experience playing Quadball, prior history on concussion education training, and history of concussions [10,21,24,25,26,27]. Informed consent was obtained from each participant prior to administering survey questions via a Qualtrics (Qualtrics, Seattle, WA, USA) online survey to all participants via email in a de-identified, anonymous manner [28].

2.3. Statistics

Survey data were tabulated to calculate the modified CKI and the CAI. Descriptive data were collected using Stata Version 14 (StataCorp LLC, College Station, TX, USA) and Microsoft Excel (Microsoft, Redmond, WA, USA) for frequency and percentages for this cross-sectional study.

3. Results

3.1. Demographics

A total of 237 participants successfully participated in the online survey assessment, and 205 participants completed the modified CKI and CAI components (86.5% response rate). A total of 202 participants reported they were current or former Quadball players, and 64 participants reported they were current or former Quadball coaches. Of the participants with previous Quadball playing experience, they had an average of 4.5 ± 2.4 years of playing experience (range = 1–12 years). According to the US Quadball region, the players who participated in this survey were most frequently from the Northeast region (n = 52), followed by the Mid-Atlantic region (n = 35) and the West region (n = 34). Participants were more often affiliated with a college team (n = 135) than an adult club team (n = 68) (Table 1). Regarding concussion history, 57.8% of participants reported having some form of prior concussion training or education.

3.2. Summary

Participants (n = 217) answered a cumulative total of 77.0% correctly based on the indicated “True” and “False” answer choices. The mean modified CKI score was 19.7 ± 1.8 (range 13–28) (Figure 1). The mean modified CAI score of participants was 54.7 ± 5.5 (range 28–55) (Figure 2). Results of the RoCKAS validity scale demonstrated that participants answered 99.5% of questions correctly. Additionally, a total of 90.2% (n = 184) of participants believe that they know what to do and who to contact if they believe they have a concussion. Notably, all concussion symptoms provided in the survey were greater than or equal to the 80.0% identification rate, with headache demonstrating the highest symptom identification at 100% (Table 2). Among symptoms that were indicated as symptoms of a concussion, difficulty speaking demonstrated over a 25% identification rate. Regarding the reasons patients would not report concussion symptoms, the most frequent reason was “I did not know at the time that I had a concussion” at 87.9%, followed by “I do not think my concussion was serious enough to report” at 63.3%. There were no other reasons reported above 50% by participants (Figure 3).

4. Discussion

The sport of Quadball continues to grow in popularity throughout the United States. As an emerging full-contact sport, there is an imperative need to survey and monitor participants for injury development and risk factors. The current body of literature on Quadball sports epidemiology has only emerged in the past decade [12,13,14,15]. However, while these studies have observed injury trends within this sport, there has yet to be a study examining the profile of player attitude and awareness regarding preventing a sports-related injury. This limited understanding is coupled with the detrimental effects of concussion underreporting across sports athletes, as seen in the previous literature [29,30,31]. To the best of our knowledge, this is one of the first investigations that examines the knowledge, attitudes, and awareness of sports concussions among Quadball players.
Overall, the findings of this study demonstrate a descriptive profile of sports concussion knowledge and attitudes among Quadball participants. The distribution of the Quadball regions of the players and coaches demonstrates that there was no overwhelming statistical majority as to any playing region. Hence, the results of this study may be applicable across regions until the time there is further future scientific investigation within individual regions. Moreover, this seems to be the first study in the United States Quadball cohort that examines players and coaches across multiple teams, as prior investigations have been limited to one organization [12]. Additionally, the finding that less than 60% of survey participants had some form of prior concussion training or education is particularly interesting as it may suggest that there is a need in the future to develop a concussion education curriculum designed specifically for Quadball players. Future study designs should be conducted to evaluate the benefit of such an educational program by utilizing similar knowledge survey methodology pre- and post-program [9,32,33,34]. The implementation of a concussion education intervention will still require further investigation in order to create a program that is effective in improving player knowledge [35].
Furthermore, this assessment was offered to all US Quadball players and coaches who were registered for the 2021 playing season. It is important to note that the results of this study only included players from adult club and college teams. The cumulative 77.0% accuracy of the modified CKI questions found among Quadball participants is comparatively higher than the accuracy found among rugby player populations [36]. Compared to this rugby cohort, this Quadball cohort was also found to have answered more questions on the modified CKI at a rate of over 80% [36]. Moreover, the mean modified CKI score of the Quadball cohort was also higher than that of other cohorts, including soccer, American football, rugby, and motorsport athletes [21,36,37,38]. This mean CKI finding was also higher than in an assessment conducted with reserved military officer training cadets [39]. Additionally, the 57.8% of Quadball participants having some form of prior concussion training or education was also higher than that reported among the English football player population. This finding is encouraging regarding the overall knowledge base of the Quadball participants, and it may also indicate a greater availability and intent to utilize peripheral concussion education interventions among this playing population when compared to other cohorts of contact sport players. Despite this baseline knowledge, there still may be avenues to further educate Quadball players by utilizing an in-season concussion education intervention [38]. The mean modified CAI score of this Quadball cohort was 54.7 but was lower than other findings across other contact sports, including football, kickboxing, and rugby players [26,37,40,41]. This lower CAI suggests that attitudes are not favorable towards concussion reporting. The validity score was high in this study (>99%), which indicates further support for this finding.
The responses in this assessment indicate that the threshold of reporting a concussion among players is based on the presence of symptoms or severity, which is subjective to the player. Particularly, there was over a 60% response rate for participants reporting, “I do not think my concussion was serious enough to report”. Likewise, the most common reasoning provided by players to not report a concussion was “I did not know at the time that I had a concussion”. Despite this, participants in this study were able to successfully identify all concussion symptoms with greater than or equal to 70% accuracy. Moreover, the subjective desire to report a concussion may provide further clarity on whether it is player desire or player knowledge that serves as the primary reason for not reporting a concussion.
Overall, this study cohort demonstrated knowledge, symptom recognition, and comparable attitudes regarding concussions when compared to other contact sports. This key finding is supported through this study’s use of the modified RoCKAS methodology. Compared to the traditional RoCKAS methodology, this study uses fewer questions. The authors decided to further streamline the questions for participants and make the direct comparisons with other studies with the RoCKAS questionnaire that is difficult to correlate. Although the RoCKAS questionnaire has been used in numerous studies over the past decade and has excellent comparative ability, there still remains a need to further investigate this through other concussion knowledge questionnaires to see if the findings are parallel to the findings of this study [42,43,44].
One key strength of this study is the large sample size [26,37], which is comparably larger than the study populations in published literature regarding other contact sports, including kickboxing, rugby, and soccer [25,26,41,44]. To the best of our knowledge, this is the largest cohort sample size among Quadball players in the United States and improves awareness of this understudied sports population. However, the findings of this study are not without limitations. As a preliminary study, this current sample cannot apply to all playing populations as effectively compared to methodologies that are more narrowed toward a specific level of Quadball play. Specifically, the participants who completed this study were primarily drawn from college and adult club teams. In addition, participants completed a variety of different concussion education findings, so it is possible that there are specific concussion education interventions that create more significant improvements in CKI scores compared to others. Future investigations are required to determine which protocols work best. Additionally, age-related differences and playing experience were not analyzed in this cohort. Furthermore, the assessment methodology does not appropriately account for the nature of how these questions were answered by players who have a previous medical history of a concussion versus players who have not. Likewise, both players and coaches who participated in this study, showed no distinction between the cohorts. Discrepancies may exist among sample sizes for each assessment question because it is common in Quadball for coaches to simultaneously serve as players during the gameplay season. Likewise, while 237 individuals participated in the survey, there were discrepancies in the completion of individual sections where the total number of participants completing certain parts of the survey involved a sample size of n = 213 whereas the knowledge of concussion symptoms (Table 2) consisted of n = 205 participants. This is a key limitation of this present study, which restricts its ability to draw further statistical significance. As a result, this study serves as a descriptive profile of the frequency and percentages of the survey results. These warrant further data collection to ensure further validation of this study’s findings. Additionally, this cross-sectional study was descriptive in nature, so no further statistical analysis is provided to ensure whether the findings are statistically significant.

5. Conclusions

The findings of this study provide preliminary data regarding the attitudes, awareness, and knowledge of Quadball participants in the United States. As an emerging contact sport, there is a critical need to provide data to clinicians and researchers to adapt gameplay and develop innovative player safety interventions. The findings of this study indicate that the wealth of knowledge regarding sports concussions by Quadball participants is greater than or comparable to other contact sports, such as rugby or soccer. A key strength of this study is its large sample size and ability to cover player populations across all regions in the United States. However, there remains a need for further investigations regarding the Quadball player population in the United States. Future investigations can focus on player region-specific populations or the utilization of other subjective concussion assessment methodologies. Likewise, these data can be used in future cohort analyses with real-time concussion epidemiology data in future investigations.

Author Contributions

Conceptualization, S.S. and C.S.; methodology, S.S.; validation, R.M., D.C. and K.B.; investigation, D.C. and R.M.; S.S.; writing—original draft preparation, S.S.; writing—review and editing, R.M. and D.C.; visualization, K.B.; supervision, C.S.; project administration, S.S. and K.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of the University of Missouri Kansas City School of Medicine (protocol code 265322, date of approval 11 June 2020).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw, deindentified data supporting the conclusions of this article will be made available by the authors on request.

Conflicts of Interest

S.S., R.M., and D.C. report volunteer roles within the Department of Risk Management in US Quadball.

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Figure 1. Summary data of modified Concussion Knowledge Index.
Figure 1. Summary data of modified Concussion Knowledge Index.
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Figure 2. Summary data of modified Concussion Attitude Index (CAI).
Figure 2. Summary data of modified Concussion Attitude Index (CAI).
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Figure 3. Reason reported by participants to not report concussion symptoms.
Figure 3. Reason reported by participants to not report concussion symptoms.
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Table 1. Study Demographics.
Table 1. Study Demographics.
CharacteristicFrequency (n)Percent (%)
Former/Current Quadball Player
   Yes20299.0
   No21.0
Former/Current Quadball Coach
   Yes6431.5
   No13968.5
US Quadball Region
   Great Lakes188.9
   Mid-Atlantic3517.3
   Midwest2914.4
   Northeast5225.7
   Northwest73.5
   South115.4
   Southwest167.9
   West3416.8
Team Type
   College13566.5
   Adult Club6833.5
   High School00.0
   Youth Club00.0
   Other00.0
Concussion History
   Non-Sports Related3014.7
   Sports Related10551.5
   Quadball Related9144.6
Concussion Training/Education
   Yes11857.8
   No8642.2
Table 2. Knowledge of Concussion Symptoms.
Table 2. Knowledge of Concussion Symptoms.
SymptomsFrequency (n)
Concussion Symptoms
Headache205
Sensitivity to Light198
Difficulty Remembering192
Drowsiness166
Feeling in a “Fog”188
Feeling Slowed Down164
Difficulty Concentrating197
Dizziness201
Not Concussion Symptoms
Hives0
Difficulty Speaking166
Arthritis2
Panic Attacks47
Weight Gain5
Reduced Breathing Rate49
Excessive Studying2
Hair Loss0
Headache205
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MDPI and ACS Style

Singh, S.; Borthwick, K.; Martin, R.; Collins, D.; Shaw, C. Education and Awareness of Sports Concussion Detection and Management in Quadball: A Cross-Sectional Study. Emerg. Care Med. 2025, 2, 25. https://doi.org/10.3390/ecm2020025

AMA Style

Singh S, Borthwick K, Martin R, Collins D, Shaw C. Education and Awareness of Sports Concussion Detection and Management in Quadball: A Cross-Sectional Study. Emergency Care and Medicine. 2025; 2(2):25. https://doi.org/10.3390/ecm2020025

Chicago/Turabian Style

Singh, Som, Kiera Borthwick, Rebecca Martin, Demetrius Collins, and Christopher Shaw. 2025. "Education and Awareness of Sports Concussion Detection and Management in Quadball: A Cross-Sectional Study" Emergency Care and Medicine 2, no. 2: 25. https://doi.org/10.3390/ecm2020025

APA Style

Singh, S., Borthwick, K., Martin, R., Collins, D., & Shaw, C. (2025). Education and Awareness of Sports Concussion Detection and Management in Quadball: A Cross-Sectional Study. Emergency Care and Medicine, 2(2), 25. https://doi.org/10.3390/ecm2020025

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