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Athletic Trainers, Doctors Assess, Manage Most Concussions in High School Sports

Recommends more concussion training of primary care physicians

 

Concussions account for 15 percent of injuries in high school sports, most are managed by athletic trainers (ATs) and primary care physicians (PCPs), one in five are assessed by computed tomagraphy (CT scan), and 2.5% of athletes continue to be returned to play by a non-medical professional, finds a new study.1

Based on its findings, the study recommended:

  • Increased education of primary care physicians: Because many primary care physicians do not have adequate resources or understanding of current concussion management practices, the study's authors called for increased training and educational outreach targeting pediatricians, internists, and family practitioners.
  • MRIs instead of CT scans, where necessary. Although the high rate of CTs ordered by emergency room physicians (75.0%) was to be expected, and more acceptable, for ruling out more serious, life-threatening brain injuries such as bleeding in the brain, the CT rate among neurologists (72.2%) is "probably higher than it needs to be," said study lead author, William P. Meehan, III, director of the Sports Medicine Clinic at Children's Hospital Boston, and a MomsTeam concussion expert.  Because it is superior in detecting traumatic brain lesions and and does not, unlike a CT scan, expose patients to radiation (which a 2012 study3 by the National Cancer Institute, found slightly increases the risk of leukemia and brain cancer), MRI is recommended, where indicated, in assessing traumatic sport-related brain injuries, especially after the acute period. 
  • More study of computerized neuropsychological testing.  Such testing is now used in the evaluation of 4 out of 10 concussions in high schools with at least one athletic trainer on staff, up from one in four just one year earlier.  "Given its rapid rise in usage in the high school setting, future research should focus" on its use in concussion management, the reports says.  Neuropsychologist Rosemarie Scolaro Moser, Ph.D, Director of the Sports Concussion Center of New Jersey, Director of Research Programs for the International Brain Research Foundation, and MomsTeam.com's youth sports concussion neuropsychologist, counseled caution in the use and interpretation of post-concussion test results in making the important return to play decision. Given "recent scientific research describing factors that affect the test results and their interpretation, such as attention deficit disorder, learning disorders, group versus individual testing, invalid baselines, motivation/effort, emotions, and other environmental and individual factors,"  Moser viewed interpretation of neuropsychological tests, to the extent done "in cookbook fashion by untrained or undertrained individuals" ( e.g non-neuropsychologists) as "problematic."
  • Eliminating return to play of athletes by non-medical professionals.  While only 2.5% of return to play decisions were made by non-medical personal (such as parents and coaches), "I hope we can do better," said Meehan.   As returning to play before symptom resolution can be associated with poor outcomes, such as second impact syndrome, efforts should be made to decrease the number of athletes being returned to play by non-medical personnel.  The study suggests that, while the percentage is likely higher in those schools that, unlike those in the study, do not employ ATs - as is true in 42% of U.S. high schools -  the percentage will likely go down as result of legislation now in place in a growing majority of states requiring medical clearance before a return to play.

Concussion by type

  • A surprisingly high 15 percent of injuries among high school athletes are concussions;
  • Three quarters of all recorded concussions were sustained by male athletes;
  • Nearly nine of out ten concussions were the athlete's first; and
  • Of the one in ten that were recurrent, more than a third (37%) occurred with the same school year, 6 in 10 (61.3%) followed a concussion sustained in an earlier school year.

Concussion totals and rates by sport

As expected, rates of concussion per athletic exposure (AE)(defined as one athlete participating in one organized high school athletic practice or competition regardless of the amount of time played) were highest for collision sports, such as football, boys' ice hockey, and boys' lacrosse:

  • Nearly half (47.2%) of the total number of concussions were sustained by football players;Football player holding head in pain
  • Concussions represented the highest percentage of total injuries, in the following sports:
    • boys' ice hockey (24.2%)
    • cheerleading (20.7%)
    • girls' lacrosse (19.1%)
    • football (19.1%); and
    • boys' lacrosse (18.9%)

But, while the study found that concussions represent a higher proportion of all injuries sustained in boys' ice hockey than other sports, football had the highest rate of sport-related concussions per 100,000 AEs:

  • Boys' football: 76.8
  • Boys' ice hockey: 61.9
  • Boys' lacrosse: 46.6
  • Girls' soccer: 33.0
  • Girls' lacrosse: 31.0
  • Girls' field hockey: 24.9
  • Boys' wrestling: 23.9
  • Boys' basketball: 21.2
  • Boys' soccer: 19.2
  • Girls' basketball: 18.6
  • Girls' softball: 16.3
  • Cheerleading: 11.5
  • Girls' gymnastics: 8.6

The authors suggested that the discrepancy may have resulted from increased media attention on football leading to an increase in the diagnosis of concussion, as has recently been reported by the National Football League.

Concussions by symptoms

Consistent with other recent studies, the five most commonly reported symptoms of concussion were:

  1. headache (94.3%)
  2. dizziness/unsteadiness (75.5%)
  3. difficulty concentrating (53.9%)
  4. confusion/disorientation (44%)
  5. visual disturbance/sensitivity to light (34.4%)

Consistent with other recent studies, loss of conciousness was rare, associated with only 4.2% of all concussions, while amnesia was recorded for 21.6% of concussions.

Concussions by treater

  • The vast majority of concussions are assessed and managed by athletic trainers* and primary care physicians, not sports medicine subspecialists.  The percentage of concussions assessed by medical professional:  
  • Most concussions (62.7%) were assessed by more than one medical professional.  Of those concussed athletes seen by more than one medical professional, 87.4% were assessed by an athletic trainer and a primary care physician and 7.6% by an AT and an orthopedic surgeon.

Duration of symptoms

The duration of symptoms athletes experienced after sport-related concusisons was consistent with previous studies:

  • Less than 15 minutes: 4.2%
  • 15-29 minutes: 3.3%
  • 30-59 minutes: 3.3%
  • 1-11 hours: 6.8%
  • 12-23 hours: 5.9%
  • 1-3 days: 33.8%
  • 4-6 days: 20.6%
  • 1 week-1 month: 19.2%
  • More than 1 month: 2.8%
Dr. Moser, for one, "wondered about the accuracy" of the report by nearly one fourth (23.5%) of the study participants that their symptoms had cleared within 24 hours, "considering our knowledge of the neurochemical cascade (temporary metabolic and neuronal changes in brain function)2 that can take days to occur, with special caution in the recovery of youth."

Return to play

Timing of Return to Play
Percentage of All Concussed Athletes Percentage of Athletes Returned to Play by Athletic Trainer Percentage of Athletes Returned to Play by Physician
1-2 days
 4.7  6.4  2.5
3-6 days  20.7  25.5  14.9
7-9 days
 30.0  31.9  28.7
10-21 days
 34.5  31.1  39.3
More than 22 days
 4.5  2.5  6.7
Medical disqualificaton for season
 5.4  2.7  7.1
Medical disqualification for career
 0.3  0.0  0.7

The fact that return to play intervals, once adjusted for other potential factors, were found in the same between ATs and physicians, said Meehan "might help convince [the 58% of U.S. high schools that don't have ATs] of the importance of ATs."

Gender: good news and bad news

The finding that female athletes were more likely than their male counterparts to have symptoms that lasted longer than 7 days (26.4% versus 19.6%) were all consistent with previous studies.  The gender difference was noteworthy, said Meehan, because it "adds to previous literature that suggests more significant symptoms and poorer neuropsychological assessments in female athletes after sustaining sports-related concussions."

There was, however, good news in the study on gender equality in the treatment of concussions:

  • When sports played by both boys and girls were analyzed, there was no difference in the likelihood of a medical professional being on site at the time of the injury.  
  • Gender was also not significantly associated with:
    • the timing of return to play,
    • whether the athlete was returned to play by a medical professional, or
    • which medical professional (AT or physician) made the return to play decision.

Study limitations

Dr. Meehan cautioned that, because all schools included in the study had an athletic trainer caring for their athletes, generalizing the findings to high schools that do not employ ATs was "not recommend[ed]." 

The study also may have simultaneously under- and over-reported concussions: given the difficulty of diagnosing concussions, some may have gone undetected. While all concussions, dental injuries, and fractures brought to the attention of athletic trainers were recorded, other injuries, such as contusions, strains and sprains were only recorded if they resulted in time lost from play.  "The percentage of all sport-related injuries accounted for by concussion would be smaller if minor injuries that did not result in time lost from play were included."

* At high schools which have athletic trainers 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. Giza CC, Hovda DA, The Neurometabolic Cascade of Concussion. J. Ath Train 2001;36(3):228-235.

3. Pearce MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. June 7, 2012 (published online ahead of print). 

Posted October 9, 2011, revised June 20, 2012

 

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Great article and very

Great article and very timely. 2nd Impact Syndrome is very serious. Does the amount of time between concussions matter? What is the preferred time to keep a child from a collision sport if they have suffered a concussion?

Time between concussions

Good question. Most MDs say until all signs and symptoms disappear --it could be two weeks or two months. But, never shorter than about a week.

 

 

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