unique relationship and daily contact they typically have with the athletes. The best approach to tracking an athlete’s symptoms is to utilize a graded symptom checklist as outlined in the National Athletic Trainers’ Association’s Position Statement on Management of Sports-Related Concussion (Guskiewicz, Bruce, Cantu, et al., 2004). Portions of the observation and palpation should take place during the initial on-field evaluation. The athletic trainer should observe for any deformities or abnormal facial expressions, speech patterns, respirations and movement of the extremities. Gentle palpation of the skull and cervical spine should be performed to rule out a fracture. If the athlete is unconscious, care must be taken not to move the head and neck. A helmet should only be removed at this time if it compromises maintenance of adequate ventilation. An adequate airway can be maintained by simply removing the face mask or strap. A quick cranial nerve assessment can be conducted, which includes checking visual acuity (CNII: optic), eye movement (CNIII & CNIV: oculomotor & trochlear), and equality of pupillary size and reaction to light. The development of an unusually slow heart rate or an increased pulse pressure (increased systolic and decreased diastolic) after the athlete has calmed down may be indicative of increasing intracranial involvement. The overwhelming majority of concussions will not reveal positive results for these tests; however, they are important considerations for detecting a more serious injury such as a hematoma. The athletic trainer must be capable of identifying deteriorating conditions warranting immediate advanced medical care.
Special Tests Research has demonstrated neuropsychological and balance testing provides objective information. Advanced neuropsychological assessment is strongly recommended and will be discussed in a companion paper within this volume. However, brief mental status tests such as the Standardized Assessment of Concussion (SAC), are sensitive measures often used by athletic trainers on the sideline and in the athletic training room during the initial 48 hours after the injury (McCrea, Guskiewicz, Barr, et al., 2003; McCrea, 2001). Balance testing is another important tool that athletic trainers should use when managing concussion. The Balance Error Scoring System (BESS) is recommended as a rapid, cost-effective method of objectively assessing balance in athletes following a concussion. Three different stances (double-legged, singlelegged, and tandem) are completed twice, once on a firm surf ace and again on a piece of medium-density foam (Airex, Inc) for a total of six trials. The BESS has been shown to be a reliable and valid assessment tool for managing concussion (Guskiewicz, Ross, and Marshall, et al., 2001; McCrea, Guskiewicz, Barr, et al., 2003). Comparing the concussed athlete’s postinjury scores to baseline scores, and tracking recovery is an effective way to help ensure a safe return to participation. Counseling the Athlete Following the initial evaluation, the athletic trainer should counsel the athlete by explaining the injury and the dangers of returning to play while still symptomatic. In the high school setting, this interaction should take place alongside the parent and coach. Emphasis should be placed on the potential of a more catastrophic injury such as Second Impact Syndrome and
the increased susceptibility for future concussions if not managed properly. Athletes who previously sustain a concussion are at a significantly higher risk for concussion compared to their non-concussed counterparts (Zemper, 2003; Schulz, Marshall, Mueller, et al., 2004; Guskiewicz, Weaver, Padua, et al., 2000; Guskiewicz, McCrea, Marshall, 2003), emphasizing the need for accurate and empirically-based return to play (RTP) decisions. Therefore, it is important for the athletic trainer to know the athlete’s concussion history, and to gain his or her trust and willingness to report concussive injuries.
Return to Play The athletic trainer now has an array of tools and techniques that should be used for the on-field management of concussion, and objectivity in RTP decisions. Symptomatology, neurocognitive function, and balance are all pieces contributing to the concussion puzzle and no one piece should be used to the exclusion of others. At the very least, all signs and symptoms should be resolved prior to considering a return to play. When same-day return to play is being considered, symptoms should be evaluated both at rest and after exertional maneuvers such as jogging, sit-ups, and push-ups. Athletes with a concussion history should be managed extra cautiously, because they often experience more serious symptomatology and slower recovery compared to those without prior concussion (Collins, Lovell, Iverson, et al., 2002; Guskiewicz, McCrea, Marshall, 2003). Youth athletes and those who experience loss of consciousness or amnesia should never be returned to participation on the same day. Athletic trainers should work with the team physician, and other medical personnel assisting in the management of the injury to establish a graded progression of physical and cognitive exertion once the athlete is asymptomatic. For example, light aerobic exercise is followed by sport-specific training (i.e. dribbling, shooting baskets, walkthroughs, etc), and noncontact training drills. These activities are followed by full contact drills, and then return to play. Progression from one level of exertion to the next is predicated on the absence of postconcussion signs and symptoms at the previous level. Concussion Prevention Prevention should begin with education, and the athletic trainer is responsible for initiating this. For sports involving high contact, the athletic trainer should have a conversation with the players and coaches prior to the start of the season. During this meeting, the athletic trainer should explain “concussion” in the context of signs and symptoms, as well as the potential negative consequences (i.e. Second Impact Syndrome, predisposition to future concussions, etc.) of not reporting a concussive injury. Educational materials, such as the Centers for Disease Control and Prevention toolkits are available and have proven to be very useful in educating young athletes (CDC, 2005; CDC 2007a, CDC 2007b). Once the athlete has a better understanding of the injury, they can provide a more accurate report of their injury as well as report on any prior concussions which is useful information when managing future injuries. Athletic trainers can also ensure the athlete is equipped with appropriately certified and properly-fitting protective equipment. The athletic trainer should work closely with the equipment manager to select and fit the athlete with the best available helmets. In many settings, the athletic trainer participates with BRAIN INJURY PROFESSIONAL
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