Previous research suggests that health care providers, in general, are not adequately trained in sport-related concussion (SRC) recognition and management. However, it is unclear if athletic training educators are instructing athletic training students on evidence-based SRC assessment and management protocols.
To examine and identify which SRC resources and management tools are being used to teach and prepare athletic training students to clinically evaluate and manage SRCs.
Single Web-based survey.
One hundred two athletic training educators.
Survey questions collected education level, years of experience as an athletic trainer, sex, role within the athletic training program, and the type of athletic training program at their institution. Participants were asked which position statement or consensus statement was used to teach SRC and, finally, which SRC management tools were taught to students in regard to SRC evaluation, management, and return to play.
Respondents have been certified athletic trainers for an average of 17.9 ± 6.5 years and accumulated a mean of 9.9 ± 6.8 years of clinical experience before transitioning into educational roles. Among the respondents to the survey, 99% of educators are using the National Athletic Trainers' Association position statement to teach SRC. The clinical examination (100%) was the most widely taught evaluation tool among respondents. Out of all the respondents, over 80% of educators are teaching clinical use and application of the Sport Concussion Assessment Tool 3, Balance Error Scoring System, and computerized neurocognitive testing; however, only 71% are teaching the stepwise progression, and less than 30% are teaching newer tools documented in SRC literature.
Educators are following recommended practices of teaching a multifaceted approach to SRC evaluation and management. However, instruction is lacking on the use of a stepwise return-to-play progression and newer SRC management tools that assess vestibular and ocular-motor impairment.
Commission on Accreditation of Athletic Training Education educators are instructing athletic training students on sport-related concussion position statements and following recommended practices of teaching a multifaceted approach to concussion evaluation and management.
Commission on Accreditation of Athletic Training Education educators have not provided students with as much hands-on experience using sport-related concussion evaluation and management tools assessing the ocular and vestibular systems.
We recommend educators become current with new clinical tools through workshops, seminars, and conferences to provide students with more hands-on experience administering a variety of sport-related concussion management tools.
Sport-related concussion (SRC) has reached epidemic levels in the United States with approximately 4.1 million sport and recreational traumatic brain injuries occurring annually.1 Of the many issues surrounding SRC, assessing and managing concussed athletes is at the center of attention. Athletic trainers are the primary health care providers responsible for the onfield assessment of a concussed athlete,2 and current consensus and position statements recommend that sports medicine clinicians adopt a multifaceted approach for the diagnosis and management of SRC.2–5 However, research has shown that athletic trainers are not following these recommendations and are deviating from the standard of care, beginning at the initial evaluation through return to participation protocols.6–9
Athletic trainers should incorporate a clinical examination, symptom checklist, neurocognitive tests, and balance/postural stability measures when evaluating a concussed athlete.2 However, research has indicated that only 47% to 76% of athletic trainers are administering at least 32,3 of these recommended SRC measures.6,7,9,10 Even fewer athletic trainers are using 3 or more of these tools to make return-to-play decisions (34%–64%).7–9 These findings indicate that athletic trainers are not following the National Athletic Trainers' Association (NATA) position statement2 on SRC. It is unclear why there is a lack of compliance using best practices for SRC management. Therefore, it is imperative to determine which SRC resources and management tools are being used to teach and prepare athletic training students to clinically evaluate and manage concussive injuries.
Previous research suggests that physicians or medical students are not adequately trained in SRC recognition and management.11–13 In a study completed in 2015, approximately half of Canadian family physicians and emergency department physicians, and 27% of pediatricians, reported never having heard of any consensus statements on SRC.14 Additionally, Donaworth et al12 surveyed American medical students' knowledge of concussion and found that only 59% of students knew that loss of consciousness was involved in less than one-third of all SRCs, and only 43% recognized that emotional affect and personality changes were symptoms of SRC. Even more startling was the fact that 30% of students felt it was acceptable to only administer a minimental exam for SRC assessment, and 59% did not know that a concussed athlete should successfully complete a symptom-free, 5-day stepwise exertion-based progression prior to returning to activity. While the literature demonstrates that physicians are not receiving sufficient education on SRC and the associated management tools, there is a lack of literature investigating what athletic training students are being taught regarding SRC.2–5 Due to the vital role athletic trainers play in the evaluation and management of SRCs, it is important to understand what athletic training educators are exposing students to within respective athletic training curriculums. Although exposure does not equate to a direct clinical application, athletic trainers may be less likely to use SRC management tools they have not been exposed to.
Sport-related concussion injuries often lead to neuromotor and motor control deficits, and consensus statements specify that at least 1 or more motor-control assessments can provide useful information for SRC assessment and management.2,3 Traditionally, motor control has been assessed and managed through use of balance testing.2 Balance deficits as a result of a SRC have been attributed to the failed ability to integrate vestibular and ocular-motor sensory information.15–17 The tool most widely used by athletic trainers to assess vestibular and ocular-motor dysfunction related to balance is the Balance Error Scoring System (BESS).2,7 Recently, new tools have emerged that have shown promise18–24 in assisting in the evaluation of vestibular and ocular-motor dysfunction related to SRC that are not currently highlighted in the position and consensus statements. Examples of these SRC tools are the King-Devick (K-D), Sway Balance, and Vestibular and Ocular Motor Screening (VOMS) tests. Preliminary research suggests that vestibular and ocular-motor impairment and symptoms (eg, dizziness, vertigo, imbalance) occur in 61 to 81% of youth athletes with SRC.18–20 The K-D test measures saccadic eye movement and attention via a rapid number naming task.21 The couple of published studies on the K-D test provide initial evidence for the utility of the K-D test in detecting SRC.22,23 However, Baugh et al6 reported that fewer than 3% of sports medicine clinicians administer the K-D test during diagnosis and management of a concussed athlete.6 The VOMS is a newer tool that was designed to assess vestibular and ocular-motor impairment postconcussion in the absence of baseline data.18,24 Published studies have demonstrated that the VOMS is highly sensitive in identifying an athlete with a concussion,18 and it also yields a low false-positive rate of 11%.24 Moreover, the VOMS has higher internal consistency than other commonly used screening tools to assess saccadic eye movements and vestibular function.24
The Professional Education Council of the NATA was responsible for the 5th edition of the Athletic Training Education Competencies, which includes the following: “Identify the signs, symptoms, interventions and, when appropriate, the return-to-participation criteria for brain injury including concussion.”25(p22) However, no research to date has examined educators who teach in Commission on Accreditation of Athletic Training Education (CAATE) accredited athletic training programs and what they are teaching and exposing athletic training students to in regard to SRC evaluation and management. Given the rapidly evolving SRC measures and best practices for SRC management, it is imperative that athletic training educators incorporate up-to-date materials in their teaching of this important injury. Therefore, the purpose of this study was to identify which SRC resources and management tools are being used to teach and prepare athletic training students to clinically evaluate and manage concussive injuries.
Participants were recruited though the CAATE Web site. Program directors for all athletic training programs are listed by institution, name, and e-mail address on the CAATE Web site. A total of 377 program directors were e-mailed directly in spring 2016. The recruitment e-mail included an overview and explanation of the study, as well as a link to the Web-based survey. Program directors were asked to forward the survey link to the individual associated with the athletic training program responsible for teaching SRC material. Two reminder e-mails were sent over the course of 6 weeks following the initial e-mail.
The instrument used for this study was a 24-item questionnaire that was adapted and modified from a 17-item questionnaire previously used in research.26 Covassin et al26 modified the original instrument used by Ferrara et al27 in 2001. Covassin et al26 added items that evaluated which SRC evaluation and management tools athletic trainers incorporated into their clinical teaching practices. The current study adapted the instrument further to include more current assessment and management tools due to advances in SRC knowledge and care practices over the last decade. The instrument modifications were reviewed for face and content validity by a panel of SRC researchers and athletic training program directors (n = 5).
The questionnaire was designed to evaluate teaching trends among athletic training program directors and athletic training educators in relation to the assessment and management of SRC. The first part of the survey collected demographic information including education level, years of experience as an athletic trainer, sex, their role within the athletic training program, and the type of athletic training program at their institution (ie, professional bachelor's, professional master's, postprofessional master's, Doctorate of Athletic Training).
Following demographics, participants were asked whether they used the NATA position statement,2 consensus guidelines from Zurich,3 Cantu,28 American Academy of Neurology,5 or American College of Sports Medicine.29 All position statements were published in 2014 or earlier, so respondents had at least 2 years to familiarize themselves with each statement. Data for this study were collected prior to the release of the most recent Concussion in Sport Group International consensus statement that was published in April 2017. Participants were asked if they were teaching grading scales for assessment and return-to-play management of concussion and which definition of concussion they were teaching within their respective programs. Four questions evaluated which specific items athletic training programs incorporate into their SRC teaching practices by asking participants to choose all the items that they use to teach the assessment of concussion, management of concussion, and concussion return to play. Response options included: an athlete self-report, the Sport Concussion Assessment Tool 3 (SCAT3), the Standard Assessment of Concussion, a postconcussion symptom score checklist (PCSS), computerized neurocognitive tests, the BESS, the Romberg balance test, tandem walking, the Sway Balance, force plates, the VOMS, the K-D, concussion grading scales, a physician's return-to-activity clearance, and a graduated stepwise return-to-play progression. Four questions addressed whether the administration and interpretation of computerized neurocognitive testing was taught to students and if students are being taught to use the graduated stepwise progression to make return-to-play decisions. Finally, participants were asked if students were being taught state legislation regarding youth sport concussion and if students were taught the clinical trajectories related to concussion care and treatment. The survey was administered via the Qualtrics (Provo, UT) online survey software. The survey took approximately 10 minutes to complete.
Study approval was obtained by the university's institutional review board. The consent form was listed as the first page of the electronic survey, and consent was implied when the respondent proceeded with survey completion. Any individual who did not agree to participate in this study was able to terminate the survey without any repercussions. Participants were allowed to withdraw from the survey at any time without penalty and were allowed to skip questions. All responses were anonymous, and no identifiable information was collected. Data collection took place over 6 weeks.
Participant responses were exported from Qualtrics into an IBM SPSS (version 23; SPSS Inc, Chicago, IL) spreadsheet for data management and analysis. Descriptive frequencies were completed on all demographic information in order to gain a better understanding of the sample of athletic training educators included in this study. Frequency statistics were calculated for each item pertaining to SRC education practices.
Of the 377 athletic training educators who were contacted for participation, a total of 109 participants initiated the survey, which resulted in a 28.9% response rate. There were 7 individuals who were excluded because they did not complete any information beyond the consent page (n = 5) or completed the demographics section only (n = 2). This left 102 participants who were included in statistical analyses, as they partially (n = 10) or fully (n = 92) completed the survey questions regarding SRC education practices. Due to the inclusion of responses from those who completed only a portion of the survey, each item has its own unique response rate that varies from 92 to 102. This is denoted by reporting the response frequency out of the total number of participants that completed each item. The sample had a mean age of 42.6 ± 9.5 years with 61 female participants (59.8%), 40 males (39.2%), and more than half having earned a doctoral degree (n = 60, 58.8%). The sample reported that they had been certified athletic trainers for a mean of 17.9 ± 6.5 years and accumulated a mean of 9.9 ± 6.8 years of clinical experience before transitioning into educational roles. The majority of participants were athletic training program directors (n = 81, 79,4%) with the rest being clinical education coordinators (n = 7, 6.9%), professors (n = 10, 9.8%), and preceptors (n = 4, 3.9%). Those who responded represented institutions that had professional bachelor's (n = 93, 91.2%), professional master's (n = 18, 17.6%), postprofessional master's (n = 12, 11.8%), Doctorate of Philosophy (n = 1, 1.0%), and Doctorate of Athletic Training (n = 2, 2.0%) education programs. See Table 1 for a complete, detailed breakdown of participant demographic information.
Resources Used for Sport-Related Concussion Education
Participants reported that they used a variety of resources to educate their athletic training students about SRCs (Table 2). The NATA position statement (n = 101/102, 99%) and International Conference on Concussion in Sport consensus statement (n = 83/102, 81.4%) were clearly the most used resources used for SRC education by our sample. A total of 45.1% (n = 46/102) of the sample reported that they taught the Centers for Disease Control and Prevention HEADS UP program, and 39.2% (n = 40/102) indicated that they used SRC resources from the American College of Sports Medicine. The least commonly used SRC resource was the Cantu guidelines with only 25.5% (n = 26/102) of the sample reporting that they taught it to their students. Furthermore, a total of 95.7% (n = 88/92) of the athletic training educators who responded to the survey indicated that they discussed current state SRC legislation as part of their SRC education.
Sport-Related Concussion Management
The most commonly taught SRC management tools were the SCAT3 (n = 90/94, 95.7%), BESS (n = 88/94, 93.6%), athlete symptom self-report (n = 85, 90.4%), and computerized neurocognitive tests (n = 84/94, 89.4%). The graduated stepwise progression (n = 56/94, 59.6%), K-D (n = 36/94, 38.3%), Sway Balance (n = 31/94, 33.0%), VOMS (n = 21/94, 22.3%), force plates (n = 10/94, 10.6%), and concussion grading scales (n = 8/99, 8.1%) were the least commonly taught SRC management tools. The majority of respondents (n = 75/92, 81.5%) said they teach their athletic training students to tailor postinjury care and treatments to individual systems (ie, vestibular, ocular, migraine, psychosocial) that may be affected by a SRC. Additionally, 90.2% (n = 83/92) of the sample made a point to emphasize evidence-based practice for SRC management. Refer to Table 3 for the results of all SRC management tools investigated in this study.
Sport-Related Concussion Return-to-Play Decisions
Components that were commonly incorporated as part of the SRC return-to-play decision-making process were computerized neurocognitive tests (n = 84/94, 89.4%), the athlete symptom self-report (n = 81/94, 86.2%), SCAT3 (n = 81/94, 86.2%), BESS (n = 76/94, 80.9%), and PCSS checklist (n = 76/94, 80.9%). A physician's return-to-activity clearance (n = 74/94, 78.7%) and graduated stepwise progression (n = 67/94, 71.3%) were instructed as part of the SRC return-to-play process by approximately three-fourths of athletic training educators in this sample. Similar to the concussion management tool results, the K-D (n = 24/94, 25.5%), VOMS (n = 15/94, 16.0%), and concussion grading scales (n = 7/99, 7.1%) made up the least commonly taught SRC return-to-play resources (Table 4).
Hands-On Experience Using Sport-Related Concussion Management Tools
Athletic training educators reported their students gained the most hands-on experience administering the SCAT3 (n = 86/94, 91.5%), computerized neurocognitive tests (n = 82/94, 87.2%), and the BESS (n = 80/94, 85.1%). Less than one-third of participants reported that their students gained experience using the K-D (n = 25/94, 26.6%) and VOMS (n = 15/94, 16.0%; Table 5). When asked specifically about how their students are educated on computerized neurocognitive tests, 59.7% (n = 55/92) reported their students are administered a computerized neurocognitive test to complete individually, 80.4% (n = 74/92) instruct their students on how to administer a computerized neurocognitive test, and 59.7% (n = 55/92) educated their students on how to read and interpret the computerized neurocognitive test results.
The purpose of this study was to identify which SRC resources and management tools are being used to teach and prepare athletic training students to clinically evaluate and manage concussive injuries. We focused on the resources used to educate athletic training students about SRC management and return-to-play decision making. This study found that the use of the NATA position statement2 and International Conference on Concussion in Sport consensus statement3 to educate athletic training students on SRC has increased by approximately 19% (80.2 to 99%) and 66% (15.3 to 81.4%), respectively, since 2009.26 Although athletic training educators are using SRC evidence-based practice and position statements more so now than ever to teach a multifaceted approach to injury management, education on the use of a stepwise return-to-play progression and tools related to vestibular and ocular-motor aspects of SRC management is still lacking.
The entire study sample reported that they educated their students on the importance of using a clinical examination for SRC management. Additionally, we found that the SCAT3, BESS, athlete symptom self-report, computerized neurocognitive testing, and PCSS checklist were the major items of the clinical exam taught by 80% or more of respondents for SRC management. These findings suggest that athletic training educators are teaching their students the components of the multifaceted approach to SRC management that are described in the most recent edition of the NATA position statement.2
Although the components of the multifaceted approach are integrated into educational content, it appears that students are not getting as much hands-on experience with individual concussion management tools as they should. For example, while approximately 80% of students are being instructed on how to administer a computerized neurocognitive test (ie, Immediate Post-Concussion Assessment and Cognitive Testing, Concussion Resolution Index), only 60% are taught how to read and interpret results, and only 60% are given the opportunity to experience taking one of these tests. One explanation for the lack of student test taking could be due to the cost associated with most computerized neurocognitive testing programs. Additionally, if a school does not have a standing contract with one of the testing programs, it is difficult to provide athletic training students with the opportunity to complete the test.
The use of computerized neurocognitive testing in athletic training has increased over 40% since 2009.7,26 Approximately 75% of athletic trainers are using some form of computerized neurocognitive testing,7 and this could be the result of increased exposure to these tools as an athletic training student. Exposure to SRC resources and management tools within an athletic training program does not necessarily translate to what tools athletic trainers choose to use once they begin clinical practice; however, the 40% increase in use may be directly related to athletic training educators including neurocognitive testing into the teaching of SRC management tools over the last few years. Neurocognitive testing protocols have been viewed as the cornerstone of SRC management,30 but when neurocognitive protocols are used as standalone tools, they do not always provide the clinician with results that are clinically sensitive to concussion.31–33 Thus, such neurocognitive tests should be taught as a component of a multifaceted approach. Computerized neurocognitive tools are designed to evaluate information processing, planning memory, and switching mental set30 ; therefore, if students are learning how to administer the test, it is critical that they are taught how to clinically interpret test results. Moreover, computerized neurocognitive testing platforms are heavily used in the collegiate and high school levels; thus, it is suggested that the advantages and limitations31,33–35 of these testing methods are also incorporated into their athletic training education curriculum.
Hands-on experience with concussion evaluation and management tools is critical for the preparation of athletic trainers. About 96% of athletic training students are getting hands-on experience with the SCAT3, a useful sideline assessment that incorporates cognitive and balance measurements. Approximately 85% of students are getting hands-on experience with the BESS test, 71.3% with the PCSS, and 64.9% with the Standard Assessment of Concussion; however, only 26.6% are getting experience with the K-D, and 16% are getting experience with the VOMS. The K-D and VOMS are newer tests, in addition to Sway Balance and balance testing on force plates. Consensus statements highlight the importance of assessing balance functions when a concussion is suspected.2–5 Balance deficits, as a result of concussion, have been associated with the failure to integrate sensory information stemming from the vestibular and ocular-motor components of the balance mechanism.15–17 Therefore, an assessment of 1 or more motor control systems, including ocular-motor and vestibular, is warranted to diagnose and manage concussive injuries. The BESS test has traditionally been used as the hallmark baseline and postinjury balance tool because it requires minimal cost, has high portability, and demonstrates high injury sensitivity.32,36 Although the BESS test is a useful and effective measurement of balance, it may not be the most accurate measurement to assess a balance deficit in a concussed athlete with a history of ankle injuries.37 Thus, newer ocular-motor and vestibular testing platforms, such as the K-D, VOMS, and Sway Balance offer additional alternatives to be used to assess vestibular and ocular-motor dysfunction associated with SRC.
Similar to the BESS, the K-D, VOMS, and Sway Balance are also highly portable tools; however, they may not be as familiar to some athletic trainers because they are newer tools. One reason for the lack of teaching and exposure of the K-D, VOMS, and Sway Balance can be due to their infancy; however, literature now demonstrates that the K-D and VOMS tests possess high internal consistency.18,21,24 Sway Balance is a Food and Drug Administration-cleared mobile balance test that is used with a mobile device.38 The test is user friendly; however, it can only be used on the iOS platform with a compatible Apple mobile device, and there is little to no empirical evidence investigating the reliability and validity of this tool. The VOMS has been demonstrated to be an assessment that supports the evaluation of premorbid vestibular and oculomotor symptoms24 and is highly sensitive in identifying patients with a concussion.18 The Zurich statement3 from the 2012 consensus meeting recommended adding research regarding the K-D and that a vision test component be incorporated into the SCAT exam. Although less education is being provided to athletic training students regarding alternative vestibular and ocular-motor tools for SRC, it is important to note that 40%–50% of athletes with a SRC report dizziness and balance dysfunction18 related to impairments of the vestibulo-ocular and vestibulospinal parts of the brain.39 As research emerges and we have a better understanding of the effects and duration of SRC, the evaluation, diagnosis, and management of SRC will simultaneously evolve, and these changes must be reflected in athletic training education.
New science and clinical evidence surrounding SRC is updating on a regular basis, and educators must keep up with changes in the understanding of the injury and the resulting neuromotor and neurocognitive effects. The majority of educators (90.2%) emphasized the incorporation of evidence-based practice into the teaching of SRC, and although it takes several years for evidence to make it into clinical practice,40 it is promising that so many educators are using multiple SRC resources published within the past 2–5 years to educate athletic training students. However, results of our study suggest that educators need to incorporate evidence related to additional vestibular and ocular-motor SRC assessment and management tools. As athletic training education programs matriculate future sports medicine clinicians, it is advised that students understand and synthesize the most up-to-date SRC management tools in order to stay current within the field. Although athletic training students may not integrate each and every tool into clinical practice, it is critical that they understand the benefits and limitations of each tool and the importance of using multiple tools for SRC management and return-to-play decisions.
In regards to return-to-play decision making, our results indicate that the integration of position statements2–5 into teaching practices may not be as strong when considering the proper stepwise progression in the return-to-play process. The use of a graduated stepwise progression is a process that is stressed in multiple position statements and most athlete and parent SRC education materials, but only 71.3% of our sample reported that they formally trained students on how to use one for reintegration into activity participation. A lack of education on this systematic approach to activity reintroduction is particularly concerning when considering the potentially serious repercussions of returning an athlete to participation before they have fully recovered from a concussive injury.2,3 Premature return to play could lead to catastrophic consequences in adolescent and pediatric athletes3 and long-term consequences.41
This study had a few limitations that need to be addressed. First, the response rate was low, which may contribute to the answers not being representative by all CAATE education programs. Second, like with all survey research, participants may not have been honest and accurate with all their answers. Finally, not all respondents may be teaching the course on SRC education (ie, could be an adjunct faculty member). However, the survey was predominantly completed by CAATE program directors, who should be aware of what content is used for SRC instruction. Future research should concentrate on the transfer of SRC education into clinical practice. It is important to know if athletic training students are able to transfer their SRC knowledge to real-world settings and if exposure to SRC tools within an educational setting lead to clinical use of SRC tools. Additionally, future research should look into continuing education regarding SRC that athletic training educators receive.
It appears that CAATE educators are instructing athletic training students on SRC evidence-based practice and position statements. Educators are following recommended practices of teaching a multifaceted approach to concussion evaluation and management through the use of sideline assessments (ie, SCAT3), BESS, clinical exam, and computerized neurocognitive testing. However, there appears to be a lack of instruction on the use of a stepwise return-to-play progression and emerging SRC management tools that evaluate vestibular and ocular-motor deficits. Moreover, educators are exposing students to many tools, but have not provided students with hands-on experience using these tools. Thus, it is suggested that educators stay up to date on new clinical tools through workshops, seminars, and conferences and provide students with more hands-on experience administering a variety of SRC management tools.
Dr Wallace is currently Assistant Professor and Master of Athletic Training Program Director of Kinesiology and Sport Science at Youngstown State University. Please address all correspondence to Jessica Wallace, PhD, AT, ATC, Kinesiology and Sport Science, Youngstown State University, 1 University Plaza, 307L Beeghly Center, Youngstown, OH 44555. email@example.com.