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Athletic Trainer Plays Critical and Unique Role In Concussion Safety

 

Certified athletic trainers (ATs) play a key role in the assessment of concussions in high school sports and the critical return to play decision.

ATs are on the front lines in the concussion safety battle.  According to a 2011 study, [1] while physicians were present at the time of injury in only 7.7% of cases of reported concussions suffered by high school athletes in the 2009-2010 school year,* ATs were on site for at least 70%.  When present, they almost always were involved in assessing an athlete for concussion (94.4%). 

The presence of an AT dramatically increases the chances that a concussion will be diagnosed, which is critical to avoiding not only a more lengthy recovery but the risk of permanent brain damage.  A research paper [2] presented in October 2012 at the American Academy of Pediatrics National Conference and Exhibition in New Orleans, LA found that 8 times more concussions were diagnosed in girls' high school soccer and 4.5 times more in girls' basketball in high schools with ATs than those without ATs.

"This data shows the valuable role that [ATs] can play in preventing, diagnosing and managing concussions and other injuries," said Cynthia LaBella, MD, FAAP, the author of the paper presented at the AAP conference, told Science Daily.   "Athletic trainers have a skill set that is very valuable, especially now when there is such a focus on concussions and related treatment and care.  Concussed athletes are more likely to be identified in schools with athletic trainers and thus more likely to receive proper treatment." 

Invaluable member of assessment team 

There are a number of reasons why an AT is such an invaluable member of the concussion assessment team:

  • Athletic trainers have concussion training. 
    • Since their specialty is sport-related injuries, an athletic trainer, in general, will know as much, if not more, about sports-related concussions than other health care professionals who do not have an interest in sports medicine or concussive brain injury. [3]
    • A  2006 survey [4] found that many primary care physicians (e.g. pediatricians, internists, and family practitioners) were either unaware of current management guidelines or found the guidelines too confusing to put into practice, and that only 16% had reliable access to neuropsychological testing within 1 week of injury.  Since they were found in the 2011 study [1] to be involved in assessing 6 out of 10 concussions suffered by high school athletes, the authors said "efforts to support [PCPs] in this regard could have a major influence on management."
    • A 2012 survey [9] found that nearly one in 3 (30%) primary care providers (PCPs) identified inadequate training as a significant barrier for prescribing a gradual return to play protocol for concussed athletes.
    • In attempting to explain concussion reporting behavior by athletes, a 2014 study [11] noted the existence of "environmental constraints that influence reporting behavior, irrespective of intention [to report]," including the increased likelihood that athletes will report symptoms "if there are personnel on the sideline they perceive to be qualified to diagnose a concussion [or] who they perceive to be sympathetic to their report or who ask them if they are experiencing symptoms." 
  • Athletic trainers know the athletes best. The AT may also be better able to identify subtle signs that an athlete has suffered a concussion because he or she knows the athlete's usual behavior and demeanor. [8]  Because they often see athletes on a daily basis, the athletic trainer is also in best position to perform the daily follow-up examinations that allow the AT and team physician to determine if the athlete is symptom-free and has successfully completed the graduated return to play protocol required for a safe return to contact or collision sports. California's new concussion safety law (AB 2127), for instance, requires a minimum 7-day waiting period after an athlete sustains a concussion before returning to play, and only after completing the RTP protocol, which must be supervised by a health care professional with concussion expertise.
  • Athletic trainers are trusted by athletes:  
    • Many athletes - as many as 50%, according to one study [5] and perhaps more - fail to, don't recognize, or are reluctant to self-report symptoms of a concussion, no doubt in part because some parents and coaches, and even the very culture of the contact or collision sport they are playing (dubbed by a recent Institute of Medicine report as the "culture of resistance")  encourages them to follow a code of silence. As a result, developing the trust of an athlete is a necessary and vital part of the process of assessing and managing a concussion and the return to play decision.
    • Because an AT often sees the athlete on a daily basis, athletes may be more comfortable reporting symptoms to them than to a physician who they do not see as regularly. 
    • Because athletes trust athletic trainers, they may also be in the best position to educate them about the signs and symptoms of concussion and the dangers that can result from not reporting concussion symptoms, including delayed recovery, permanent cognitive impairment, and, in rare cases, catastrophic injury or death from of second-impact syndrome (SIS). Indeed, a 2011 study [6] of concussions in high school sports during the 2008-2009 school year suggests that expanded access to an AT in one Northern Virginia area school district from 2 part-time ATs to 1 full-time AT and 1 part-time may have substantially increased the likelihood that a concussion was recognized and treated.
  • Athletic trainers are just as conservative as doctors in the return to play decisions. A study of concussions in high school sports during the 2009-2010 school year [1] found no difference between ATs and physicians in terms of how quickly they allowed athletes to return to play.
  • Athletic trainers reinforce message regarding conservative return to play.  As noted by the American Academy of Pediatrics' 2013 clinical statement on return to learning in the classroom following concussion,[10] "the AT can help reinforce communication of any school or sports restrictions to safeguard against the student-athlete beginning a return-to-play protocol but sill having academic adjustments."  The AAP thus encourages communication with the AT by the treating physician or school representative who has been communicating with the physician.  

Provide first-aid and triage

One of the most challenging aspects of game and practice coverage in sports is the response to injuries involving the head and cervical spine (neck). Knowledge concerning the clinical presentation and proper emergency care in the event a player suffers a potentially serious or catastrophic head or neck injury is required for athletic trainers and medical personnel.

The AT's role during games and practices is to prevent injury and provide immediate first-aid care and triage. To be properly prepared:

  • Before the season, the athletic training staff should create an emergency medical or action plan instituting all procedures that must be followed during an emergency.  Baseline computerized neuropsychological testing of athletes, particularly in collision sports such as football, hockey, and lacrosse, and contact sports with high rates of concussion, such as soccer and basketball, is recommended and has become part of the gold standard in concussion management.
  • The various entities making up the institutional medical team - the secondary support teams, including local emergency medical services, ambulance units, and level 1 trauma centers (including helicopter transport) - should be listed.
  • Policies, such as which circumstances requiring immediate removal of an athlete from play and when he or she is allowed return to play, should go through the proper administrative protocols before being instituted [Note: almost all states now require by law that athletes with suspected concussion be immediately removed from play and not allowed to return until given written clearance by a medical professional with concussion training and expertise].
  • All equipment to be used on a daily basis must be inspected and tested before each season, and in some instances, such equipment must be re-calibrated annually.  

More athletic trainers needed

Two-thirds of parents of middle-school and high school athletes said in a 2010 survey they supported a requirement that an AT be onsite for practices and games, athough there was no general agreement among the parents surveyed on how to fund the position, with less than half (43%) saying the money should come from the general school budget and 28% believing the money should come from team fundraising or athletic user fees.

The National Athletic Trainers' Association recently released preliminary data showing that approximately two thirds of U.S. secondary schools with an ongoing athletic program have access to athletic trainers (ATs), whether full-time or part-time. That's an improvement from its 2005 estimate[7] that only about 40-45% had such access. In some states, the number is much lower. (Over three-quarters of Nebraska high schools, for instance, are without ATs)

The fact that return-to-play intervals were found in the 2011 study [1]   to be the same between ATs and physicians, said its lead author, Dr. William P. Meehan, III, Director of the Sports Concussion Clinic at Children's Hospital Boston and a MomsTEAM concussion expert, "might help convince schools [that don't have ATs] of the importance of ATs."

* At high schools with at least one athletic trainer on staff. 


1. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools.  Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).

2. LaBella L. A Comparative Analysis of Injury Rates and Patterns Among Girls' Soccer and Basketball Players. Paper presented October 22, 2012 at American Academy of Pediatrics (AAP) National Conference and Exhibition, New Orleans, LA; High Schools with Athletic Trainers Have More Diagnosed Concussions, Fewer Overall Injuries. Science Daily http://www.sciencedaily.com/releases/2012/10/121022080649.htm (retrieved February 21, 2013) 

3. Meehan William Paul, III, Kids, Sports, and Concussions at p. 2 (Praeger 2011).

4. Pleacher MD, Dexter WW. Concussion management by primary care providers. Br. J. Sports Med. 2006;40(1):e2, discussion e2.

5. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players - Implications for prevention. Clin J of Sport Med 2004;14:13-17.  

6. Lincoln A, Caswell S, Almquist J, Dunn R, Norris J, Hinton R. Trends in Concussion Incidence in High School Sports: A Prospective 11-Year Study. Am. J. Sports Med. 2011; 30(10), accessed January 31, 2011 @ http://ajs.sagepub.com/content/early/2011/01/29/0363546510392326.full.pdf+html,

7. Waxenberg R, Satloff E. Athletic trainers fill a necessary niche in secondary schools. National Athletic Trainers' Association: 2009. Available at: http://www.nata.org/NR031209.

8. Harmon K, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26 (familiarity with an athlete is an important component in the sideline evaluation of a concussion, given the variability in the way concussions present).

9. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric Providers' Self-Reported Knowledge, Practices, and Attitudes About Concussion.  Pediatrics 2012;130(6). DOI: 10.1542/peds.2012-1431)(published online ahead of print)(accessed November 19, 2012). 

10. Halstead ME, et al. Clinical Report: Returning to Learning Following a Concussion. Pediatrics doi:10.1542/peds.2013-2867 (epub October 27, 2013).

11. Kroshus E, Baugh CM, Daneshvar DH, Nowinski CJ, Cantu RC.  Concussion Reporting Intention: A Valuable Metric for Predicting Reporting Behavior and Evaluating Concussion Education. Clin J Sport Med. 2014; Post Author Corrections: July 21, 2014
doi: 10.1097/JSM.0000000000000137.

Originally posted on an earlier version of this site in approximately 2002.  Most recently updated September 6, 2014

 

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