2013 NATA Position Statement on Management of Sport

2013 NATA Position Statement on the
Management of Sport Concussion
Presented by:
Jeanne Brown, MS, ATC-l
Robert Cantu, MD
 Gerard A. Gioia, PhD
 Kevin Guskiewicz, PhD, ATC
 Jeffery Kutcher, MD
 Michael Palm, MBA, ATC
 Tamara Valovich-McLeod, PhD, ATC
Available in written document by
Summer 2013 – Winter 2014
(Journal of Athletic Training)
Education and Prevention
Documentation and Legal Aspects
Evaluation and Return to Play
Other Considerations:
- Equipment
- Pediatric Concussion
- Home Care
- Medications and Diet
- Rest
- Multiple Concussions
“A trauma induced alteration in mental status
that may or may not involve loss of
Definition excludes the use of the terms: ding, bell –
ringer, clearing the cobwebs, or other antiquated
Definition reflects that provided by the Zurich group.
Proper terminology: concussion or MTBI (mild
traumatic brain injury)
Abide by educational requirements in state
regulations and/or supervisory organization
policies (i.e. NCAA or WIAA)
Educate parents and coaches on: recognition,
referral, proper return to participation, the
physical and cognitive restrictions for concussed
athletes, ramifications of improper concussion
management, and prevention.
Document potential modifying factors that could
delay a return to play and athletes should be
educated on the implications of these conditions
as it affects their recovery.
Work to educate coaches, athletes, and parents
about the limitations in protective equipment
regarding concussion prevention (i.e. helmets not
designed to prevent concussion!). Read all
warning labels associated with protective
46 states do not have legislation in place re: concussion
(Montana, Georgia, Alabama, WVA)
Awareness of any and all governing bodies and
their policies and procedures regarding concussions
(i.e. state, NCAA/WIAA, school)
Communicate the status of concussed athletes to a
physician on a regular basis.
Ensure proper documentation of the concussion
evaluation, management and treatment, return to
participation progression, and physician
High risk athletes should receive a baseline
The Baseline should include:
- clinical history to include symptoms/score
- neurological evaluation: motor control (balance),
and neurocognitive function
Baseline and post-injury exams should be
administered in similar environments to maximize
performance (review baselines for sub-optimal
An athlete suspected of sustaining a concussion should
be removed from athletic participation and evaluated
by a physician or their designate (i.e. ATC or PA).
When a rapid assessment is necessary (i.e. during
competition), brief concussion evaluation tools
(SAC) should be used along with a motor control
evaluation and assessment of symptoms to support the
clinical evaluation.
Once a concussion diagnosis is made, a physical exam
should be performed and signs and symptoms
monitored at least once a day.
How Assessed
How Assessed
symptom Checklist
/ scale
Level of consciousness,
Orientation, Memory
Previous Concussions
Pre – participation
examintation (PPE)
Concusstion Related
Personal History
Eye movements with smooth
pursuit (CN III, IV, VI), nystagmus
(CN VIII), Pupillary reflex (CN II,
Family History
Strength evaluation of deltoid,
biceps, triceps, wrist and finger
flexors and extensors*; and
pronator drift
Balance assessment
During the acute recovery stage, daily testing of
neurocognitive function and motor control is not
recommended until asymptomatic.
No concussed athlete should return to physical
activity without being evaluated and cleared by a
physician or designate specifically trained in
concussion evaluation and management.
A concussed athlete should not be returned to
athletic participation within the same day as
A physical exertion progression should be conducted only once
an athlete demonstrates a normal clinical exam, symptom
resolution, and return to baseline motor control and
neurocognitive function (each stage separated by 24 hours of
being asymptomatic):
1- No activity
Light exercise
Sport-specific activities without the treat of contact
Non-contact training involving others
Unrestricted training
Unrestricted play
Concussion grading scales should not be used for the purposes
of injury management, but rather each injury should be
evaluated and treated on a case-by-case basis
Following injury resolution, the concussion may be
retrospectively graded for the purposes of medical record
documentation (i.e. mild, moderate, severe based on duration
and intensity of symptoms).
Helmets do help to prevent catastrophic head injuries,
they do not significantly reduce the risk of cerebral
Helmet use in high velocity sports (skiing, cycling) has
been shown to protect against head and facial injury.
Consistent evidence to support the use of mouth
guards for concussion mitigation is not available.
However, a properly fitted mouth guard does reduce
dental injuries (!).
The use of headbands in soccer is neither encouraged
nor discouraged at this time, as their effectiveness is
not clear based on the literature.
Children and adolescents may take longer to
recover than adults and require a more
conservative return to play progression.
Age-appropriate, validated assessment tools
should be utilized with younger populations.
Assessment of post-concussion symptoms in youth
athletes should include age-validated standardized
symptom scales and the formal input of parent
Pediatric athletes are undergoing continual brain and
cognitive development and likely need more frequent
updates to baseline assessments.
Athletic trainers should work with school
administrators and teachers to include appropriate
academic accommodations into the concussion
management plan.
Those with a complex medical history may benefit from
a referral to a neuropsychologist to administer and
interpret neurocognitive assessments (i.e. multiple
concussions, developmental disorders like ADD, ADHD,
or psychiatric disorders like anxiety and depression.
A standard concussion home-instruction form should
be consistently used with a copy maintained in the
medical record (oral and written instructions for home
care should be given to the concussed athlete and to a
responsible party).
Concussed athletes should be instructed to avoid
medications other than acetaminophen, unless
prescribed by a physician.
Concussed athletes should be instructed to avoid
ingesting alcohol, illicit drugs, or other substances that
might interfere with cognitive function and neurologic
Name and Date of injury:
Day, time and location of follow-up evaluation.
Name of number of who to contact if symptoms
Decreasing level of consciousness
Increasing confusion
Increasing irritability
Loss of/fluctuating levels consciousness
Numbness in the arms or legs
Pupils become unequal in size
Repeated vomiting
Slurred or inability to speak
Unable to recognize people or places
Worsening Headache
General Instructions to follow It is OK to:
Use acetaminophen (Tylenol) for headaches
Use ice pack on head and neck as needed for comfort
Eat a carbohydrate rich diet
Go to sleep
Rest (no strenuous activity or sports)
There is NO need to:
Check eyes with flashlight
Wake up every hour
Test reflexes
Stay in bed
Drink alcohol
Drive a car or operate machinery
Engage in physical activity (i.e. exercise, weight lifting, physical education sport
participation) that makes your symptoms worse
Engage in mental activity (i.e. school, job, homework, computer games) that makes your
symptoms worse
Rest is currently the best practice for concussion
recovery, so there is no need to wake the athlete
during the night unless instructed by a physician.
Athletes should be instructed to avoid any physical
or mental exertion that exacerbates symptoms.
In addition to exclusion from physical activity
related to team activities, concussed studentathletes should be excused from PE classes.
School administrators, counselors, and instructors
should be made aware of the athlete’s injury with a
recommendation for academic accommodation
during the recovery period.
Those not showing a typical progressive return to
normal functioning following injury may benefit
from other treatments.
An athlete with a concussion should be instructed
to eat a well-balanced diet that is nutritious in
both quality and quantity – and to remain properly
A more conservative return to play strategy should be
adopted for athletes with a concussion history.
Referral to a physician with concussion specific training
should be considered in athletes with multiple concussions
- sustaining concussions with lessening force
- demonstrates increasing severity of each injury
- and/or demonstrates a change in baseline brain function
Athletic Trainers should be particularly aware of the
potential for Second Impact Syndrome in young athletes who
sustain a 2nd concussion prior to complete resolution of the
1st injury.
The athletic trainer should be aware of the potential for longterm consequences of multiple sub-concussive impacts.
Dr. Steven Broglio, PhD, ATC – U of MI
Committee Chairs and Co-Authors for the position statement:
Robert Cantu, MD
Gerard Gioia, PhD
Kevin Guskiewicz, PhD, ATC
Jeffery Kutcher, MD
Michael Palm, MBA, ATC
Tamara Valovich McLeod, PhD, ATC

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