From the National Athletic Trainers' Association
The National Athletic Trainers' Association has released a new position statement on the management of sport concussion. The release came during the NATA's 5th annual Youth Sports Safety Summit in Washington, DC. in March 2014.
The statement is an update to the NATA's original 2004 concussion guidelines (Guskiewicz KM, et al. 2004) and addresses education, prevention, documentation and legal aspects, evaluation and return-to-play considerations. In particular, the authors amended the return-to-play guidelines and now recommend no return on the day the athlete is concussed. (Note, this brings the NATA in line with the consensus of experts, which has recommended no same-day return-to-play for a number of years).
The statement, created by the NATA Research & Education Foundation, appeared in the March 2014 issue of the Journal of Athletic Training,
"With the continued national spotlight on concussions from professional to youth sports, these recommendations provide a practical roadmap for athletic trainers, physicians and other medical professionals on injury identification and management. We also hope this document will serve as an educational tool for parents and school administrators," said Steven P. Broglio, PhD, ATC, lead author of the position statement and director of the Neurosport Research Lab in the School of Kinesiology at the University of Michigan.
"Athletic trainers (ATs) are commonly the first medical experts available on site to identify and evaluate injuries," added Broglio. "Without exception, ATs should be present at all organized sporting events - from practices to games - and at all levels of play and work closely with their physician or other designated medical expert to implement these guidelines. In light of these general protocols, each athlete should be treated on an individual basis."
Education and Prevention
The statement recommends:
- Using proper terminology such as concussion or mild traumatic brain injury (mTBI) as opposed to colloquial terms as "ding" or "bell ringer," which minimize the injury severity. The recommendation that concussion and mTBI can be used interchangeably is a departure of some of the other concussion position statements and guidelines in recent years, and there has been an ongoing debate in the medical community about using concussion and mTBI interchangeably. "Our thought was to try to highlight that a concussion is a serious injury, rather than the thought that it is just a ding or bell-ringer," said Tamara Valovich McLeod, PhD, ATC, Professor and Director of the athletic training program at A.T. Still University in Mesa, Arizona and one of the position statement's co-authors. "I understand the point [that those who argue against using the terms interchangeably make]," McLeod says, "that all concussions are mTBIs but not all mTBIs are concussions, but ATs are most often discussing the injury with parents, adolescents, and coaches, so we thought to simplify the message and denote the seriousness regardless of whether the term concussion or mTBI is used";
- Educating administrators, sports medicine team members, coaches, parents and others on concussion prevention, cause, recognition and referral, physical and cognitive restrictions for concussed athletes, return-to-play protocols and ramifications of improper concussion management;
- Documenting potential modifying factors that could delay return to participation, and educate patients on these implications; and
- Understanding limitations of protective equipment for concussion prevention, and read all warning labels associated with that equipment.
Documentation and legal aspects
The statement recommends that athletic trainers:
- Be aware of state legislation as well as sport governing bodies and their policies and procedures regarding concussion management;
- Document the athlete's (and when appropriate the parent's) understanding of concussive signs and symptoms and his/her responsibility to report a concussion; and
- Communicate the status of concussed athletes to the managing physician, document all evaluations, management, treatment, return to participation and physician communications.
"The legislation and policy area is one that is important for ATs, because they need to not only be aware of any state laws, but also their state interscholastic association policy, school district and/or school policy, and their standing orders with their directing physician," says McLeod. "It's a multi-layered system of policies in which one could be more conservative than another. Furthermore, it is important that concussions are documented well as this injury holds a high degree of [potential] liability."
The statement's discussion of the legal liability aspects of concussion management as they relate to athletic trainers, it is worth noting, is believed to be the first such discussion in a position statement regarding concussion management.
Evaluation and return-to-play
The position statement recommends that:
- Athletes at high risk of concussions (those in collision or contact sports) should undergo baseline examinations before the competitive season.
- Baseline examinations be completed annually for adolescent athletes, those with recent concussions and, when feasible, all athletes. (Note: this is a departure from other consensus statements, which do not call for annual baseline exams);
- Baseline exams should consist of clinical history , physical and neurologic evaluations, measure of motor control (balance ) and neurocognitive functions . (noticeable by its absence is a recommendation for a baseline King-Devick test, a simple vision test that a growing number of experts believe, and studies show, can help identify athletes with possible concussion on the sports sideline in making the all-important "return/no return decision");
- Any athlete suspected of a concussion should be removed from play; not allowed to return to activity on the day of injury; and received a full follow-up evaluation from a physician or AT;
- Once the concussion diagnosis is made, the patient should undergo daily focused examinations to monitor the course of recovery and be cleared by a physician before returning to play. (Note: written RTP clearance is required under the law of 48 states and the District of Columbia , although some state laws allow the written authorization for return to sports to be made by health care professionals other than a physician);
- Those athletes with a history of concussions or who do not show a typical return to normal functioning after injury (usually in about a week to 10 days, according to most studies) may benefit from a referral to a neuropsychologist (as a brand new study in Pediatrics (Kirkwood MW, et al. 2014) recommends) or additional treatments or therapies . McLeod says one of the "key aspects" of the statement lies in the fact that it "reiterat[es] the importance of the multifactorial assessment and using an interdisciplinary concussion team."
The position statement recommends:
Because research on the effectiveness of headgear in soccer players is limited, the statement says the use of headgear is neither encouraged nor discouraged at this time.
- that ATs enforce the standard use of certified (e.g. NOCSAE) helmets and educate athletes, coaches and parents that, although helmets can help prevent catastrophic injuries, they do not significantly reduce the risk of concussions;
- helmet use in high-velocity sports (e.g. skiing, cycling), which has been shown to protect against traumatic head and facial injury;
- the wearing of mouth guards because, although consistent evidence demonstrating a reduced concussion risk by wearing a mouthguard is not available, the evidence demonstrates that fitted mouthguards do reduce dental injuries;
For younger athletes, the statement recommends:
The position statement calls for:
- implementation of a standard concussion home instruction form for all patients;
- instructing a concussed patient to avoid medications other than acetaminophen, and to avoid alcohol, drugs or other substances during their concussion recovery;
- recommending rest as the best practice for concussion recovery; during the acute stage of injury (the first several days after injury) patients should avoid any physical or mental exertion that exacerbates symptoms, should maintain a healthy diet and stay well hydrated; and
- ensuring that school administrators, counselors and instructors are aware of the patient's injury.
For a comprehensive article about the parents' role in concussion treatment and recovery, click here
With respect to the management of patients with a concussion history , the statement recommends that:
- the potential for second-impact syndrome be recognized, and an awareness of the potential long-term consequences of multiple injuries; and
- referral to a physician with specific concussion training and experience be considered for athletes with a history of concussions.
Concussions: key statistics
- An estimated 3.8 million concussions occur each year as a result of sport and physical activity.
- Sport-related concussions account for 58 percent of all emergency department visits in children (8-13 years old) and 46 percent of all concussions in adolescents (14-19 years old).
- Athletes who have had one concussion are 1.5 times more likely to have a second; those who have sustained two concussions have a nearly three times greater risk and those with three or more have a 3.5 times higher risk.
- The most recent data from the High School Reporting Information Online (RIO) indicated that concussions in interscholastic athletes are responsible for 8.9 percent of all athletic injuries.
For a comprehensive article on statistics on concussions in high school sports, click here
More research needed
The clinical practice recommendations set forth in the NATA's statement are "graded" based on the Strength of Recommendation Taxonomy (SOR)(e.g. "A" is based on "consistent and good quality experimental evidence; "B" on inconsistent or limited quality experimental evidcence, and "C" on consensus, usual practice, opinion, or case series or studies of diagnosis, treatment, prevention, or screening, or extraopolations from quasi-experimental research.
As McLeod notes, "the grading of the SOR still finds a lot of recommendations graded with a "C", meaning there is limited evidence and it is based primarily off expert opinion. (In fact, 30 of the 46 recommendations are graded C) I think the number of C recommendations shows there is still a lot of research that needs to be done in many areas."
To review the NATA's statement in full, please visit: http://dx.doi.org/10.4085/1062-6050-49.1.07.
NATA Press Release, March 10, 2014
Broglio SP, et al. National Athletic Trainers' Association Position Statement: Management of Sport Concussion. J Athl Train. 2014;49(1):000-000. doi: 10.4085/1062-6050-49.1.07 (epub March 10, 2014).
Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association position statement: management of sports-related concussion. J Athl Train. 2004;39(3):280-297.
Kirkwood MW, Peterson RL, Connery AK, Daker DA, Grubenhoff JA. Postconcussion Symptom Exaggeration After Pediatric Mild Traumatic Brain Injury. Pediatrics 2014;133(4). doi: 10.1542/peds.2013-3195 (epublished March 10, 2014).
Most recently revised January 11, 2015
NATA Issues New Concussion Position Statement
The National Athletic Trainers' Association has released a new position statement on the management of sport concussion. The statement is an update to the NATA's original 2004 concussion guidelines and addresses education, prevention, documentation and legal aspects, evaluation and return-to-play considerations. In particular, the authors amended the return-to-play guidelines and now recommend no return on the day the athlete is concussed.