Which of the following is least helpful to record to aid in future testing sessions for an athlete?

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Stalso P. Broglio, PhD, ATC,* Robert C. Cantu, MD,† Gerard A. Gioia, PhD,‡ Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM,§ Jeffrey Kutcher, MD,* Michael Palm, MBA, ATC,‖ and also Tamara C. Valovich McLeod, PhD, ATC, FNATA¶

Gerard A. Gioia

‡Division of Pediatric Neuropsychology, Children"s National Medical Center, Washington, DC

Kevin M. Guskiewicz

§Department of Exercise and also Sport Science, College of North Carolina, Chapel Hill


To carry out athletic trainers, physicians, and other health care experts through best-practice guidelines for the administration of sport-associated concussions.

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An estimated 3.8 million concussions take place every year in the United States as an outcome of sport and also physical activity. Athletic trainers are typically the first clinical carriers available onsite to identify and also evaluate these injuries.


The recommendations for concussion management provided right here are based on the most existing research and divided into sections on education and learning and avoidance, documentation and also legal facets, testimonial and return to play, and various other considerations.

Key Words: mild traumatic brain injuries, pediatric concussions, education, assessment, testimonial, documentation

Despite a significant rise in research dedicated to identifying and also managing sport-related concussion, it remains one of the many complex injuries sporting activities medicine professionals confront. Concussions happen from pressures used straight or instraight to the skull that result in the rapid acceleration and deceleration of the brain. The sudden change in cerebral velocity elicits neuronal shearing, which produces changes in ionic balance1 and also metabolism.2 When accompanied by clinical signs and symptoms, alters at the cellular level are generally described as mild traumatic brain injury, or concussion. Concussions take place in males and females of all ages and in all sports, yet are many prevalent in call and collision activities. File collected from emergency department visits display a 62% rise (153 375 to 248 418) in nonfatal traumatic brain injuries in between 2001 and also 2009,3 via as many type of as 3.8 million reported and also unreported sport- and recreation-connected concussions occurring annually in the USA.4

As licensed clinical professionals, athletic trainers (ATs) get comprehensive didactic and clinical training in concussion administration. They are generally the first companies to identify and also evaluate injured persons and are integral in the postinjury monitoring and also return-to-play (RTP) decision-making procedure. Without exception, ATs have to be existing at all organized sporting occasions at all levels of play and need to job-related carefully through a doctor or designate who has specific training and suffer in concussion administration to build and implement a concussion-administration setup based upon the references outlined right here.

An upday to the initial 2004 National Athletic Trainers" Association position statement on the monitoring of sport-connected concussion,5 this record contains recommendations on concussion management for practicing ATs based on the many current scientific proof. A testimonial of the literary works sustaining these referrals has also been contained. The record covers the topics of “Education and Prevention,” “Documentation and Legal Aspects,” “Evaluation and RTP,” and “Other Considerations.”


To ideal assemble the accessible concussion study and remajor continuous with various other clinical teams, we sought to evaluate literature that characterized concussion as a “trauma-induced change in mental standing that may or might not involve loss of consciousness.”6 This definition was schosen based upon its wide application by clinical establishments and also widespreview use within the literature from the moment of the first National Athletic Trainers" Association position statement. We identify the strength of the definition offered by the Internationwide Concussion in Sport Group and also its subpoints as valid functions that even more define concussion.7 In evaluating and creating this document, we additionally included research specifying concussive injuries in these terms. Significantly absent from the literary works and continuous through previous references were the terms “ding,” “gaining one"s bell rung,” “clearing the cobwebs,” and other such phrases in reference to concussive injuries.5 These colloquial terms are antiquated, minimize injury severity, and must not be used to describe concussion or mild traumatic brain injury.

Education and also Prevention

The clinical practice references for each topic have been graded based upon the Strength of Recommendation Taxonomy (SORT; Table 1).8

Strength of RecommendationsDefinition
ARecommendation based upon regular and great top quality experimental proof (morbidity, mortality, exercise and cognitive performance, physiologic responses)
BRecommendation based on inconsistent or restricted high quality speculative evidence
CRecommendation based upon consensus; usual practice; opinion; disease-oriented evidenceb; situation series or studies of diagnosis, treatment, avoidance, or screening; or extrapolations from quasi-experimental research

2. The AT need to work through the proper administrators to encertain that parents and coaches are educated on the adhering to elements of concussion: prevention, mechanism, recognition and also referral, proper go back to participation, physical and also cognitive restrictions for concussed athletes, and implications of imappropriate concussion monitoring.10–12Strength of Recommendation: B

4. The AT have to work-related to educate coaches, athletes, and also parental fees about the constraints of protective tools for concussion prevention. Strength of Recommendation: C

5. As part of educational initiatives, ATs, athletes, coaches, and paleas should read all warning labels linked via protective equipment. Strength of Recommendation: C

Documentation and Legal Aspects

6. The AT need to be conscious of any and all appropriate governing bodies (eg, state, athletic conference) and their policies and procedures regarding concussion administration. Strength of Recommendation: C

7. The AT must document the athlete"s (and when correct, the parent"s) knowledge of concussive indications and also symptoms and also his or her duty to report a concussion. Strength of Recommendation: C

8. The AT need to interact the condition of concussed athletes to the managing doctor on a regular basis. Strength of Recommendation: C

9. The AT should encertain appropriate documentation of the concussion testimonial, management, therapy, return-to-participation progression, and physician communications. Strength of Recommendation: C

Evaluation and also RTP

12. The baseline examination must consist of a clinical background (consisting of any symptoms), physical and neurologic evaluations, actions of motor control (eg, balance), and neurocognitive feature.5,7,18–20Strength of Recommendation: B

14. Any athlete suspected of sustaining a concussion have to be automatically rerelocated from participation and also evaluated by a medical professional or designate (eg, AT). Strength of Recommendation: C

16. When the rapid assessment of concussion is vital (eg, during competition), a brief concussion-testimonial tool (eg, Standardized Assessment of Concussion 20,22,23) need to be used in conjunction with a motor-manage testimonial and symptom assessment to assistance the physical and neurologic clinical evaluation. Strength of Recommendation: B

17. Once a concussion diagnosis has been made, the patient should undergo a day-to-day focused examicountry to monitor the course of recoextremely. Strength of Recommendation: C

20. No concussed athlete must go back to physical task without being evaluated and also cleared by a doctor or designate (eg, AT) especially trained and experienced in concussion review and administration. Strength of Recommendation: C

23. Concussed athletes who carry out not show a typical steady return to normal functioning after injury may benefit from various other therapies or therapies. Strength of Recommendation: C

25. After the injury has actually readdressed, the concussion might be retrospectively graded for the purpose of medical document documentation. Strength of Recommendation: C


26. The AT must enpressure the standard usage of certified helmets while educating athletes, coaches, and also paleas that although such helmets aid to proccasion catastrophic head injuries (eg, skull fractures), they do not substantially mitigate the danger of concussions.7,27–29Strength of Recommendation: B

29. Research on the efficiency of headequipment in soccer players to minimize concussion is limited. The usage of headequipment is neither motivated nor discouraged at this time. Strength of Recommendation: C

Pediatric Concussion

32. Assessment of postconcussion symptoms in pediatric patients have to encompass age-validated, standardized symptom scales and the formal input of a parent, teacher, or responsible adult.38–40Strength of Recommendation: B

Home Care

40. In addition to exemption from physical task regarded team tasks, concussed student-athletes must be excused from any task requiring physical exertion (eg, physical education and learning classes). Strength of Recommendation: C

Multiple Concussions

44. Referral to a physician or designate through concussion training and suffer must be taken into consideration once an athlete through a history of multiple concussions sustains concussions through lessening forces, demonstrates raising severity via each injury, or demonstrates objective or subjective changes in baseline brain attribute. Strength of Recommendation: C

Education and also Prevention

When athletes, paleas, coaches, administrators, and others discuss concussive injuries, they need to use the proper medical terminology: concussion or mild traumatic brain injury. Use of such colloquial terms as “ding,” “bell ringer,” and “obtaining your bell rung” has actually a connotation that mitigates injury severity and also need to for this reason be avoided. For example, a listed decline in neurocognitive capacity at 36 hours after injury was reported in patients labeled as “dinged” whose symptoms showed up to fix within 15 minutes.9 This finding demonstrates a more severe impact of what was initially thought about a minor injury.

Before the competitive seakid, the AT must review all concussion policies and measures that outline injury meaning, signs and symptoms, and also the institution"s plan on concussion administration (view “Documentation and Legal Aspects” listed below about how state legislations and business body regulations may affect institutional concussion policy). In many instances, the AT has actually access to the many up-to-day indevelopment on concussion diagnosis and also monitoring. This information need to be disseminated to all of those involved in athlete health and wellness care as rapidly as feasible and also in an appropriate manner. These people include yet are not restricted to coaches, athletes, parents, administrators, and also various other clinical professionals. In enhancement to these papers, agencies have actually occurred educational information certain to coaches, athletes, and also parental fees that has been displayed to efficiently educate the tarobtain audience.54–56

Athletes themselves have demonstrated restricted expertise regarding concussion symptoms; even more than 50% of high college athletes57 and 70% of collegiate athletes58 did not report concussions sustained in the time of football. One reason for nonreporting was that athletes were not mindful of the indicators and also symptoms of concussion. Anvarious other study59 of high institution rugby players demonstrated more knowledge of concussion indications and also symptoms (61%); but, the athletes had restricted understanding of postinjury concussion-administration guidelines. For instance, 25% of the athletes thought loss of consciousness was required for the injury to be thought about a concussion.59 Educational techniques are reliable in enhancing athletes" awareness of concussion symptoms. Goodman et al60 found that expocertain to a concussion-symptom video game improved symptom identification among youth ice hocvital players.60 Similarly, Bramley et al61 noted that high institution soccer players that got concussion education and learning were more most likely to report concussion symptoms to their coach.

Researchers57 have actually recorded athletes" lack of willingness to report concussions to clinical personnel, so parents of youth athletes should likewise be educated to recognize indications and symptoms of concussion. Paleas (or guardians) commonly have actually the a lot of call via young athletes and also so are well positioned to report atypical behavior, yet many kind of parental fees are not properly educated on the topic of concussion.62 Sullivan et al63 reported that paleas of male high college rugby athletes were knowledgeable about the signs and symptoms (83%) and the risks linked via proceeding to play while injured (96%), yet only half were mindful of the correct RTP guidelines after injury.

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Even in the existence of an AT, coaches have actually the responsibility for recognizing the signs and also symptoms of concussion in athletes. Several researches, however, have actually presented that coaches have actually limited understanding and also many kind of misconceptions regarded concussions. In a survey of youth sports coaches, 45% of respondents thought a concussion did not call for immediate removal from a game or exercise, and also just 62% can effectively recognize appropriate postconcussion monitoring.10 In another examination,64 high institution coaches demonstrated greater in its entirety expertise of sport concussion (84%); they kbrand-new the many about injury recognition (92%) and the least around injury management (79%). Concussion-specific training is effective in enhancing injury knowledge: those attending a coaching education program10 or a coaches" workshop64 scored greater than nonattendees on their respective surveys. Sarmiento et al11 reported that 34% of high college coaches using the Centers for Disease Control and also Prevention"s “Heads Up” tool kit for concussion enhanced their concussion knowledge; particularly, they obtained expertise regarded injury indicators and also symptoms. The coaches also provided that the tool kit changed their mindsets and habits related to concussion.11 Similarly, a short (15–20 minute), interenergetic, virtual, concussion-education regime aimed at youth sporting activities coaches brought about improvements in symptom expertise, general expertise, injury misconceptions, self-efficacy, and behavioral intention.12 Collectively, these findings indicate that a brief training session on sport-concussion indications, symptoms, and injury monitoring targeted at coaching staff have the right to boost injury acknowledgment. This kind of training may ultimately benefit the AT by encouraging coaches to help determine concussed athletes and follow treatment plans.

After a concussive occasion, the AT should likewise educate the patient and any kind of added stakeholders (eg, parents and administrators) about the typical injury recoincredibly. Although injury severity and also an exact time to recover cannot be predicted automatically after injury, a lot of concussed athletes go back to their preinjury level of functioning within 2 weeks.65 However, several factors, including particular symptom fads,7,66 age, and sex,67 might affect injury recoexceptionally and delay the go back to participation (Table 2). Informing the patient about meant outcomes after injury might alleviate stress around the injury and linked symptoms.7,68

Documentation and also Legal Aspects

Certified ATs, team doctors, and also other health and wellness care providers responsible for the monitoring of patients via sport-associated concussion need to be mindful of potential liabilities associated through delivering medical coverage and also making RTP decisions for patients. Concussion administration has clinical and also legal effects, and also the risk of lawsuits is boosting for sports medication professionals. Previous lawsuits versus ATs and team physicians have addressed the premature clearing of patients and, surprisingly, withholding patients from play after concussion.69–73 As such, it is imperative for clinicians to control these injuries in a methodical manner, utilizing objective assessments, while documenting their day-to-day findings. Certain legal principles are widespread to the legislations of each state, but material distinctions exist in the decisions of the greater courts for each state and also in state statutes.74 It is, but, the duty of the AT to follow the best-practice guidelines, referrals, and also practice restrictions adopted by their corresponding occupational establishing or oversight company (eg, National Federation of State High School Associations, National Collegiate Athletic Association, National Football League) and the ideal methods for licensed ATs established, in component, by the place statements of the National Athletic Trainers" Association. In addition, ATs functioning in claims through concussion-management law are bound to follow those legislations in the event of a discrepancy via business guidelines or place statements.

To prevent litigation, ATs need to understand the basic aspects of negligence and malpractice that commonly govern claims for injury or fatality resulted in by imappropriate treatment. A tort is a private wrong or injury experienced by a perboy as the outcome of an additional person"s conduct. The law provides injured persons the best to be compensated with the recoincredibly of dameras. Torts may be intentional, meaning that the perchild intended to act, or unintentional, in that the perboy did not mentally intend to cause damage. A tort is committed once an AT stops working to act as an simple and also reasonably prudent perkid under comparable scenarios and also causes injury to one more perboy.74,75

Negligence is an unintentional tort. Negligence law was started on the principle that those who are hequipped as the result of others" carelessness or faientice to correctly carry out responsibilities should be compensated. The perchild that was hequipped has the burden of proving that the 4 legal elements of negligence are satisfied: a duty of care was owed as an outcome of a partnership that existed between the parties; the defendant bgot to the duty owed to the injured party; the breach of the duty is proved to be the cause of the harm to the plaintiff; and also actual harm, not simply the potential for injury, need to have occurred. All 4 facets of negligence must be prrange in order for the plaintiff to be compensated by the defendant for damages.75,76

Athletic trainers employed to treat and regulate athletic injuries such as concussion owe a duty of reasonable care to their patients and have actually been the taracquire of lawsuits alleging failures to accomplish the conventional of care after sport-connected injury, especially concussion. Allegations against ATs in instances of negligence after concussion most regularly include imappropriate evaluation and also trial and error of the patient, imcorrect documentation, misunderstood communications with the patient, and a lack of education and learning of the patient or the patient"s family.77 For ATs to minimize the hazard of coming to be defendants and to much better protect themselves have to a situation be filed, they have to understand also the typical of treatment for regulating particular injuries based upon the a lot of current clinical literary works. The standard of care in athletic training is defined as a person"s “legal duty to carry out wellness treatment services continual with what various other wellness treatment practitioners of the exact same training, education and learning, and also credentialing would provide under the situations.”78 Athletic trainers have the right to learn just how the traditional of treatment is applied to legal cases by researching particular situations and the firsthand experiences of those who have actually defended ATs during the litigation procedure.77

The athletic training profession should identify and also embrace conventional practice limitations and also guidelines to develop the standard of care for controlling concussions and also various other brain injuries. Ambiguity and the absence of a clear typical make it much easier for plaintiffs" lawyers to construct theories of licapability for lawsuits against ATs, alleging they breached the conventional of care after a suspected concussion.77 Lawsuits against ATs often involve the review or experimentation of the patient (or lack thereof), documentation of an injury, interactions with the patient or via a medical professional about a patient, and also education and learning of the patient.

In a 2008 The golden state instance, an AT was uncovered liable for failing to appropriately and also promptly evaluate a patient that reportedly had actually continual a concussion just to later pass out, loss, and also suffer a variety of physical injuries as an outcome of the AT"s alleged failures.79 The court ordered the defendants to pay considerable damages to the injured patient. In an additional instance, a College of Tennesview football player reextended numerous hundreds of dollars once an AT allegedly faicaused promptly report a patient"s initial and continuous symptoms to a doctor. The patient consequently continual an acute subdural hematoma in connection with an injury incurred 1 month later on.80 In an additional case, a high institution football player alleged that his AT failed to appropriately evaluate him or take seriously his reported headaches and also dizziness after a concussion and then prematudepend reverted him to play, which allegedly caused the patient to experience second-influence syndrome after a second concussion 2 weeks later on.81 In this instance, although the jury awarded no damperiods to the injured player, the cost to the defendants was 3 years of litigation, extensive legal fees and also costs, and a month-long, stressful, high-profile trial.

Another feasible allegation in the cases against ATs entails the absence of documentation in managing a sport-associated concussion. For several years, ATs have been advised to record “all pertinent information” neighboring concussions.5 The documentation of indevelopment bordering the testimonial and administration of any kind of suspected concussion need to include however not be restricted to (1) system of injury; (2) initial signs and symptoms; (3) state of consciousness; (4) findings of the physical and also neurologic examinations, symptoms, neurocognitive feature, and motor manage (noting any deficits compared via baseline); (5) instructions offered to the patient or parent (or both); (6) recommendations gave by the physician; (7) graduated RTP progression, including days and also particular activities; and also (8) appropriate indevelopment on the patient"s history of prior concussion and also linked recoexceptionally pattern(s). Though lengthy, this level of information can aid proccasion a premature go back to participation, catastrophic brain injury such as second-influence syndrome, and also legal liability. The expression “if it"s not composed, it didn"t happen” is often offered in legal situations. The question in these situations periodically becomes whether certain indevelopment is or is not “pertinent.” For instance, at some allude during a concussed athlete"s RTP development, he or she will start percreating graduated exertional exercises (view “Evaluation and also RTP” below). Daily documentation of the details bordering this development will certainly help to avoid potential litigation in the occasion that the recovery or return to participation does not continue as supposed. For instance, the days on which the trial and error was performed, the witnesses to the experimentation, the actual maneuvers the patient perdeveloped, and also the patient"s description of any kind of symptoms during or after task need to be documented. The worth of this documentation might not be realized for some time, as legal trials mainly take place years after the alleged imappropriate conduct, once it is unlikely that anyone can accurately recontact the details if they were not recorded at the moment.

At the moment of writing, all 50 states have enacted concussion regulations. Nearly every one of these legislations encompass the components of (1) educating athletes, parents, and also coaches; (2) setting up a concussion policy and emergency action plan; (3) removing the athlete from exercise or play at the time of the suspected concussion; and (4) having actually a health care provider through training in concussion management perdevelop clinical testimonial and RTP clearance. The AT have to understand the regulations of the state and also acknowledge that faiattract to warn or educate the athlete can be the basis for another feasible allegation. One straightforward method to educate athletes around the risks of concussion and proceeding to play while still symptomatic is to need them to read and sign a traditional acknowledgment form indicating that they understand the indications and also symptoms of concussion and their obligation to report a concussion (Appendix B). Some legal specialists also suggest that athletes need to authorize an acknowledgment that they understand also the warning a manufacturer has inserted on a helmet. For example, some footsphere helmets bring warnings such as this:

Contact in footsphere might cause concussion/brain injury, which no helmet can prevent. Symptoms encompass loss of consciousness or memory, dizziness, headache, nausea, or confusion. If you have actually symptoms, immediately sheight and also report them to your coach, trainer, and also paleas. Do not go back to a game or contact until all symptoms are gone and also you obtain medical clearance. Ignoring this warning might result in another and also even more severe or fatal brain injury. No helmet device can protect you from significant brain and/or neck injuries, including paralysis or fatality. To avoid these risks, do not interact in the sport of football. (Reprinted through permission of Schutt Sports.)

In catastrophic cases wright here such an acknowledgment of knowledge has not been secured by the AT, a “faientice to warn” claim virtually certainly will be made versus the AT, particularly as soon as the plaintiff alleges that the patient never before reextended from an previously injury. Hence, prior to each seachild, at a minimum, the AT should need that each athlete check out a concussion reality sheet, read the previously mentioned warning on the helmet, and also sign an acknowledgment that he or she read and also interpreted both. Not only execute these acknowledgments serve as a possible defense to a failure-to-warn claim, but under specific scenarios, they may also be offered to develop that the patient is legally responsible for his or her own injuries (if, for instance, the athlete reports symptoms to teammates yet withholds the information from team personnel and continues to play). When a defendant asserts and also have the right to present that the plaintiff"s injuries are an outcome of the plaintiff"s very own negligence, the defendant might prevail on a concept of contributory negligence or comparative negligence, which can bar the plaintiff from respanning any type of dameras whatsoever before.

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The more education the AT gives to the patient (and paleas of a patient that is a minor) concerning the threats of RTP before a complete recoincredibly after a concussion (eg, the hazard of playing while still symptomatic), the better the likelihood of success the AT will certainly have in defending against a failure-to-warn or failure-to-educate insurance claim. More importantly, amplified education to athletes need to analyze into even more increated participants, which should cause fewer catastrophic injuries.77 Finally, it is imperative that practicing ATs understand their individual state regulations on concussion administration because some claims have actually made provisions for ATs to clear a concussed athlete to RTP. However before, a medical professional through specific training and suffer in concussion administration have to still be affiliated in the in-depth approach to concussion administration outlined in this place statement. A concussion-administration plan outlining the duties and also responsibilities of each member of the sporting activities medication team have to be embraced.