Journal of Athletic Training 2004;39(3):280±297 q by the National Athletic Trainers' Association, Inc www.journalofathletictraining.org National Athletic Trainers' Association Position Statement: Management of Sport- Related Concussion Kevin M. Guskiewicz*; Scott L. Bruce²; Robert C. Cantu³; Michael S. Ferrara§; James P. Kelly\; Michael McCrea¶; Margot Putukian#; Tamara C. Valovich McLeod** *University of North Carolina at Chapel Hill, Chapel Hill, NC; ²California University of Pennsylvania, California, PA; ³Emerson Hospital, Concord, MA; §University of Georgia, Athens, GA; \University of Colorado, Denver, CO; ¶Waukesha Memorial Hospital, Waukesha, WI; #Princeton University, Princeton, NJ; **Arizona School of Health Sciences, Mesa, AZ Kevin M. Guskiewicz, PhD, ATC, FACSM; Scott L. Bruce, MS, ATC; Robert C. Cantu, MD, FACSM; Michael S. Ferrara, PhD, ATC; James P. Kelly, MD; Michael McCrea, PhD; Margot Putukian, MD, FACSM; and Tamara C. Valovich McLeod, PhD, ATC, CSCS, contributed to conception and design, acquisition and analysis and interpretation of the data; and drafting, critical revision, and ®nal approval of the article. Address correspondence to National Athletic Trainers' Association, Communications Department, 2952 Stemmons Freeway, Dallas, TX 75247. port in today's society is more popular than probably is the key to reducing the incidence and severity of sport- ever imagined. Large numbers of athletes participate in related concussion and improving return-to-play decisions. Sa variety of youth, high school, collegiate, professional, This position statement should provide valuable information and recreational sports. As sport becomes more of a ®xture in and recommendations for certi®ed athletic trainers (ATCs), the lives of Americans, a burden of responsibility falls on the physicians, and other medical professionals caring for athletes shoulders of the various organizations, coaches, parents, cli- at the youth, high school, collegiate, and elite levels. The fol- nicians, of®cials, and researchers to provide an environment lowing recommendations are derived from the most recent sci- that minimizes the risk of injury in all sports. For example, enti®c and clinic-based literature on sport-related concussion. the research-based recommendations made for football be- The justi®cation for these recommendations is presented in the tween 1976 and 1980 resulted in a signi®cant reduction in the summary statement following the recommendations. The sum- incidence of fatalities and nonfatal catastrophic injuries. In mary statement is organized into the following sections: ``De- 1968, 36 brain and cervical spine fatalities occurred in high ®ning and Recognizing Concussion,'' ``Evaluating and Mak- school and collegiate football. The number had dropped to ing the Return-to-Play Decision,'' ``Concussion Assessment zero in 1990 and has averaged about 5 per year since then.1 Tools,'' ``When to Refer an Athlete to a Physician After Con- This decrease was attributed to a variety of factors, including cussion,'' ``When to Disqualify an Athlete,'' ``Special Consid- (1) rule changes, which have outlawed spearing and butt erations for the Young Athlete,'' ``Home Care,'' and ``Equip- blocking, (2) player education about the rule changes and the ment Issues.'' consequences of not following the rules, (3) implementation of equipment standards, (4) availability of alternative assess- RECOMMENDATIONS ment techniques, (5) a marked reduction in physical contact time during practice sessions, (6) a heightened awareness among clinicians of the dangers involved in returning an ath- De®ning and Recognizing Concussion lete to competition too early, and (7) the athlete's awareness of the risks associated with concussion. 1. The ATC should develop a high sensitivity for the various Research in the area of sport-related concussion has provid- mechanisms and presentations of traumatic brain injury ed the athletic training and medical professions with valuable (TBI), including mild, moderate, and severe cerebral con- new knowledge in recent years. Certi®ed athletic trainers, who cussion, as well as the more severe, but less common, on average care for 7 concussive injuries per year,2 have been head injuries that can cause damage to the brain stem and forced to rethink how they manage sport-related concussion. other vital centers of the brain. Recurrent concussions to several high-pro®le athletes, some of 2. The colloquial term ``ding'' should not be used to describe whom were forced into retirement as a result, have increased a sport-related concussion. This stunned confusional state awareness among sports medicine personnel and the general is a concussion most often re¯ected by the athlete's initial public. Bridging the gap between research and clinical practice confusion, which may disappear within minutes, leaving 280 Volume 39 x Number 3 x September 2004 no outwardly observable signs and symptoms. Use of the vision, and so on. It is recommended that ATCs and phy- term ``ding'' generally carries a connotation that dimin- sicians consistently use a symptom checklist similar to the ishes the seriousness of the injury. If an athlete shows one provided in Appendix A. concussion-like signs and reports symptoms after a con- 10. In addition to a thorough clinical evaluation, formal cog- tact to the head, the athlete has, at the very least, sustained nitive and postural-stability testing is recommended to as- a mild concussion and should be treated for a concussion. sist in objectively determining injury severity and readi- 3. To detect deteriorating signs and symptoms that may in- ness to return to play (RTP). No one test should be used dicate a more serious head injury, the ATC should be able solely to determine recovery or RTP, as concussion pre- to recognize both the obvious signs (eg, ¯uctuating levels sents in many different ways. of consciousness, balance problems, and memory and 11. Once symptom free, the athlete should be reassessed to concentration dif®culties) and the more common, self- establish that cognition and postural stability have re- reported symptoms (eg, headache, ringing in the ears, and turned to normal for that player, preferably by comparison nausea). with preinjury baseline test results. The RTP decision 4. The ATC should play an active role in educating athletes, should be made after an incremental increase in activity coaches, and parents about the signs and symptoms as- with an initial cardiovascular challenge, followed by sociated with concussion, as well as the potential risks of sport-speci®c activities that do not place the athlete at risk playing while still symptomatic. for concussion. The athlete can be released to full partic- 5. The ATC should document all pertinent information sur- ipation as long as no recurrent signs or symptoms are rounding the concussive injury, including but not limited present. to (1) mechanism of injury; (2) initial signs and symp- toms; (3) state of consciousness; (4) ®ndings on serial test- ing of symptoms and neuropsychological function and postural-stability tests (noting any de®cits compared with Concussion Assessment Tools baseline); (5) instructions given to the athlete and/or par- ent; (6) recommendations provided by the physician; (7) 12. Baseline testing on concussion assessment measures is date and time of the athlete's return to participation; and recommended to establish the individual athlete's ``nor- (8) relevant information on the player's history of prior mal'' preinjury performance and to provide the most re- concussion and associated recovery pattern(s).3 liable benchmark against which to measure postinjury re- covery. Baseline testing also controls for extraneous variables (eg, attention de®cit disorder, learning disabili- Evaluating and Making the Return-to-Play Decision ties, age, and education) and for the effects of earlier con- cussion while also evaluating the possible cumulative ef- 6. Working together, ATCs and team physicians should agree fects of recurrent concussions. on a philosophy for managing sport-related concussion be- 13. The use of objective concussion assessment tools will help fore the start of the athletic season. Currently 3 approaches ATCs more accurately identify de®cits caused by injury are commonly used: (1) grading the concussion at the time and postinjury recovery and protect players from the po- of the injury, (2) deferring ®nal grading until all symp- tential risks associated with prematurely returning to com- toms have resolved, or (3) not using a grading scale but petition and sustaining a repeat concussion. The concus- rather focusing attention on the athlete's recovery via sion assessment battery should include a combination of symptoms, neurocognitive testing, and postural-stability tests for cognition, postural stability, and self-reported testing. After deciding on an approach, the ATC-physician symptoms known to be affected by concussion. team should be consistent in its use regardless of the ath- 14. A combination of brief screening tools appropriate for use lete, sport, or circumstances surrounding the injury. on the sideline (eg, Standardized Assessment of Concus- 7. For athletes playing sports with a high risk of concussion, sion [SAC], Balance Error Scoring System [BESS], symp- baseline cognitive and postural-stability testing should be tom checklist) and more extensive measures (eg, neuro- considered. In addition to the concussion injury assess- psychological testing, computerized balance testing) to ment, the evaluation should also