Tamara C. Valovich McLeod

National Athletic Trainers' Association Position Statement: Management of Sport Concussion

OBJECTIVE To provide athletic trainers, physicians, and other health care professionals with best-practice guidelines for the management of sport-related concussions. BACKGROUND An estimated 3.8 million concussions occur each year in the United States as a result of sport and physical activity. Athletic trainers are commonly the first medical providers available onsite to identify and evaluate these injuries. RECOMMENDATIONS The recommendations for concussion management provided here are based on the most current research and divided into sections on education and prevention, documentation and legal aspects, evaluation and return to play, and other considerations.

Knowledge, attitude, and concussion-reporting behaviors among high school athletes: A preliminary study

CONTEXT Many athletes continue to participate in practices and games while experiencing concussion-related symptoms, potentially predisposing them to subsequent and more complicated brain injuries. Limited evidence exists about factors that may influence concussion-reporting behaviors. OBJECTIVE To examine the influence of knowledge and attitude on concussion-reporting behaviors in a sample of high school athletes. DESIGN Cross-sectional study. SETTING Participants completed a validated survey instrument via mail. PATIENTS OR OTHER PARTICIPANTS A total of 167 high school athletes (97 males, 55 females, 5 sex not indicated; age = 15.7 ± 1.4 years) participating in football, soccer, lacrosse, or cheerleading. INTERVENTION(S) Athlete knowledge and attitude scores served as separate predictor variables. MAIN OUTCOME MEASURE(S) We examined the proportion of athletes who reported continuing to participate in games and practices while symptomatic from possible concussion and the self-reported proportion of recalled concussion and bell-ringer events disclosed after possible concussive injury. RESULTS Only 40% of concussion events and 13% of bell-ringer recalled events in the sample were disclosed after possible concussive injury. Increased athlete knowledge of concussion topics (increase of 1 standard deviation = 2.8 points) was associated with increased reporting prevalence of concussion and bell-ringer events occurring in practice (prevalence ratio [PR] = 2.27, 95% confidence interval [CI] = 1.60, 3.21) and the reporting prevalence of bell-ringer-only events overall (PR = 1.87, 95% CI = 1.38, 2.54). Athlete attitude scores (increase of 1 standard deviation = 11.5 points) were associated with decreases in the proportion of athletes stating they participated in games (PR = 0.74, 95% CI = 0.66, 0.82) and practices (PR = 0.67, 95% CI = 0.59, 0.77) while symptomatic from concussions. CONCLUSIONS Most recalled concussion events in our study were not reported to a supervising adult. Clinicians should be aware that knowledge and attitude influence concussion reporting. Clinicians and administrators should make concussion education a priority and encourage an optimal reporting environment to better manage and prevent concussive injuries in young athletes.

Serial administration of clinical concussion assessments and learning effects in healthy young athletes

Objective:To determine if serial administration of the Standardized Assessment of Concussion (SAC) and Balance Error Scoring System (BESS) would elicit a learning effect in young athletes and to determine the intratester reliability of scoring the BESS. Design:A prospective study of 50 healthy young athletes who were assigned to either the control or practice group. All subjects were administered the assessments on 2 occasions, 60 days apart. In addition, subjects in the practice group received serial administration of the assessments on 3 occasions in the week following the initial assessment. Setting:University Sports Medicine/Athletic Training Research Laboratory. Subjects:Fifty uninjured young athletes between 9 and 14 years of age. Main Outcome Measured:Scores on 2 clinical concussion assessments, the SAC and the BESS. Results:We found a significant learning effect upon serial BESS testing in the practice group. BESS error scores were significantly lower than baseline (15.0 ± 4.6) on days 5 (11.3 ± 5.33), 7 (12.4 ± 6.2), and 60 (12.6 ± 6.2). We also found a significant learning effect upon the day 60 BESS administration across all subjects. We did not find a practice or learning effect with serial SAC test administration. The intratester reliability of the investigator’s ability to score repeated observations of the same BESS test ranged from 0.87 to 0.98. Conclusions:Our results demonstrated that serial administration of the BESS elicited a learning effect, which was more prominent during the tandem conditions. Clinicians utilizing the BESS as a measure of postural stability should be aware of the potential for improvement with repeated testing. Clinicians should not expect improvement with the SAC, as scores remained relatively stable across all trials.

National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries.

OBJECTIVE To provide certified athletic trainers, physicians, and other health care professionals with recommendations on best practices for the prevention of overuse sports injuries in pediatric athletes (aged 6-18 years). BACKGROUND Participation in sports by the pediatric population has grown tremendously over the years. Although the health benefits of participation in competitive and recreational athletic events are numerous, one adverse consequence is sport-related injury. Overuse or repetitive trauma injuries represent approximately 50% of all pediatric sport-related injuries. It is speculated that more than half of these injuries may be preventable with simple approaches. RECOMMENDATIONS Recommendations are provided based on current evidence regarding pediatric injury surveillance, identification of risk factors for injury, preparticipation physical examinations, proper supervision and education (coaching and medical), sport alterations, training and conditioning programs, and delayed specialization.

Representative Baseline Values on the Sport Concussion Assessment Tool 2 (SCAT2) in Adolescent Athletes Vary by Gender, Grade, and Concussion History

Background: To improve and standardize the sideline evaluation of sports-related concussion, the Sport Concussion Assessment Tool 2 (SCAT2) was developed. This tool assesses concussion-related signs and symptoms, cognition, balance, and coordination. This newly published assessment tool has not established representative baseline data on adolescent athletes. Hypothesis: Representative baseline SCAT2 scores in adolescent athletes will differ by gender, grade in school, and self-reported concussion history. Study Design: Descriptive epidemiology study. Methods: Interscholastic athletes were administered the SCAT2 during a preseason concussion baseline testing session. The SCAT2 total score ranges from 0 to 100 points, with lower scores indicating poorer performance. Overall, representative values were calculated using descriptive statistics. Separate independent-samples t tests, with gender and concussion history as the independent variables, and a 1-way analysis of variance, with grade as the independent variable, were conducted to assess differences in SCAT2 total score (P < .05). Results: There were 1134 high school athletes (872 male and 262 female) who participated. The SCAT2 total score across all participants was 88.3 ± 6.8 (range, 58-100); skewness was −0.86 ± 0.07, and kurtosis was 0.73 ± 0.14. Male athletes scored significantly lower on the SCAT2 total score (P = .03; 87.7 ± 6.8 vs 88.7 ± 6.8), and 9th graders (86.9 ± 6.8) scored significantly lower than 11th (88.7 ± 7.0) and 12th (89.0 ± 6.6) graders (P < .001). Athletes with a self-reported concussion history scored significantly lower on the SCAT2 total score than those with no concussion history (P < .001; 87.0 ± 6.8 vs 88.7 ± 6.5). Conclusion: These data provide representative scores on the SCAT2 in adolescent athletes and show that male athletes, 9th graders, and those with a self-reported concussion history scored significantly lower than their female, upperclassmen, or nonconcussed peers. Clinical Relevance: These results suggest that healthy adolescent athletes display variability on the SCAT2 at baseline. Therefore, clinicians should administer baseline assessments of the SCAT2 because assuming a perfect baseline score of 100 points is not appropriate in an adolescent athlete population.

Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part I: disablement models.

OBJECTIVE To present and discuss disablement models and the benefits of using these models as a framework to assess clinical outcomes in athletic training. BACKGROUND Conceptual schemes that form the basic architecture for clinical practice, scholarly activities, and health care policy, disablement models have been in use by health care professions since the 1960s. Disablement models are also the foundation for clinical outcomes assessment. Clinical outcomes assessment serves as the measurement tool for patient-oriented evidence and is a necessary component for evidence-based practice. DESCRIPTION Disablement models provide benefits to health professions through organization of clinical practice and research activities; creation of a common language among health care professionals; facilitation of the delivery of patient-centered, whole-person health care; and justification of interventions based on a comprehensive assessment of the effect of illness or injury on a persons overall health-related quality of life. Currently, the predominant conceptual frameworks of disability in health care are those of the National Center for Medical Rehabilitation Research and the World Health Organization. Disablement models need to be understood, used, and studied by certified athletic trainers to promote patient-centered care and clinical outcomes assessment for the development of evidence-based practice in athletic training. CLINICAL AND RESEARCH ADVANTAGES: For clinicians and researchers to determine effective athletic training treatments, prevention programs, and practices, they must understand what is important to patients by collecting patient-oriented evidence. Patient-oriented evidence is the most essential form of outcomes evidence and necessitates an appreciation of all dimensions of health, as outlined by disablement models. The use of disablement models will allow the athletic training profession to communicate, measure, and prioritize the health care needs of patients, which will facilitate organized efforts aimed at assessing the quality of athletic training services and practices and ultimately promote successful evidence-based athletic training practice.

Pediatric Sports-related Concussion

This article aims to examine pediatric concussion literature with respect to epidemiology, etiology, return to play, and recurrent concussions, and to provide recommendations for future research. We conducted a review of pediatric concussion literature regarding incidence, etiology, return to play, and recurrent concussive injury by using MEDLINE, CINAHL, Sport‐Discus, and PsychInfo databases from 1995‐2010. A review of reference lists in the aforementioned articles was also performed. We discovered that the research on sports‐related concussion specific to children and adolescents is rather limited. Results of existing studies of concussion incidence in this population indicate that concussion is relatively rare compared with most musculoskeletal injuries; however, the potential consequences of mismanagement and of subsequent injury warrant significant attention regarding injury recognition and recovery, and the challenge of determining readiness to return to play. Evidence exists that children and adolescents take longer to recover than adults after a concussion, which underscores the need for a more conservative approach to management and return to physical and cognitive activities. Concussion in the young athlete is of specific concern because of the continuing cognitive maturation, therefore, the recovery may be more difficult to track when using the standard assessment tools currently available. Until future studies can better delineate the mechanisms of, response to, and recovery from concussion in the young athlete, it is prudent to act in a conservative manner when dealing with pediatric athletes with concussion.

Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives

Abstract Objective: To assess the influence of psychosocial determinants from the Theory of Reasoned Action and Planned Behaviour (TRA/TPB) on concussion-reporting intentions. Methods: The present study employed the TRA/TPB to develop a cross-sectional survey to examine contributors to intention to report concussion symptoms. High school athletes (n = 167, age = 15.7 ± 1.4) completed this survey. The TRA/TPB constructs of attitude (perceptions about concussion reporting), subjective norm (perception of important social referents beliefs about concussion reporting), perceived behavioural control (perceived control over concussion reporting) and intention to report concussion symptoms served as the independent variables. Linear regression models were used to predict intention to report concussion symptoms. Binomial regression models were used to predict concussion-reporting behaviours from intention. Results: Direct attitude, subjective norm and direct perceived behavioural control were all associated with intention to report concussion. Intention was associated with decreased prevalence of participating in practices and games while symptomatic from concussion. Conclusions: Favourable attitudes toward reporting and social referents’ beliefs have the greatest impact on intention to report concussion symptoms. Reporting intention may not always be an indicator of concussion-reporting behaviours. Concussion education initiatives should focus on improving attitudes and beliefs among athletes, coaches and parents to promote better care-seeking behaviours among young athletes.

Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part II: clinical outcomes assessment.

OBJECTIVE To provide an overview of clinical outcomes assessment, discuss the classification of outcomes measures, present considerations for choosing outcomes scales, identify the importance of assessing clinical outcomes, and describe the critical link between the utilization of disablement models and clinical outcomes assessment. BACKGROUND Clinical outcomes are the end result of health care services. Clinical outcomes assessment is based on the conceptual framework of disablement models and serves as the measurement method for the collection of patient-oriented evidence, a concept central to evidence-based practice. DESCRIPTION Clinical outcomes management refers to the use of outcomes measures in the course of routine clinical care and provides athletic trainers with a mechanism to assess treatment progress and to measure the end results of the services they provide. Outcomes measures can be classified as either clinician based or patient based. Clinician-based measures, such as range of motion and strength, are taken directly by clinicians. Patient-based measures solicit a patients perception as to health status in the form of questionnaires and survey scales. Clinician-based measures may assist with patient evaluation, but patient-based measures should always be included in clinical assessment to identify what is important to the patient. CLINICAL AND RESEARCH ADVANTAGES: Evidence-based athletic training practice depends on clinical outcomes research to provide the foundation of patient-oriented evidence. The widespread use of clinical outcomes assessment, based on the disablement model framework, will be necessary for athletic trainers to demonstrate the effectiveness of therapies and interventions, the provision of patient-centered care, and the development of evidence-based practice guidelines.

Identification of sport and recreational activity concussion history through the preparticipation screening and a symptom survey in young athletes.

Objective:To evaluate the concussion history of young athletes using three questions on the preparticipation screening (PPS) and a concussion symptom survey (CSS). Design:Descriptive survey. Setting:Mass high school PPS. Patients or Other Participants:Five hundred twenty young athletes. Interventions:Athletes were asked about their concussion history using three different questions on the PPS. The CSS, a list of concussion-related symptoms, was also given to assess the history of concussion-related symptoms associated with a previous injury to the head. Main Outcome Measures:Positive concussion history was determined as a positive response on one of the three PPS questions or any one of the CSS responses and reported as frequencies and percentages. Kappa coefficients were used to evaluate the agreement between the responses on the three PPS questions. Results:There was little agreement among the three PPS questions, with kappa coefficients ranging from κ = −0.018 to 0.342. Analysis of the CSS revealed that 286 athletes (55.0%) reported having at least one concussion symptom after a head injury. Of those reporting symptoms, 86.4% did not report a concussion history in sport, and 92.7% did not report a concussion history in recreational activities. Conclusions:The identification of concussion history may depend on the phrasing of questions on the PPS. Simply asking an athlete whether they had a concussion may not adequately identify athletes with concussion histories. Although recommendations have been made to avoid the terminology of ding and bell rung, it seems these terms may be needed to ensure adequate reporting of previous concussions in young athletes.