National Athletic Trainers’ Association Bridge Statement: Management of Sport-Related Concussion

The 2014 statement and the current bridge statement education and prevention recommendations are outlined in Table 1.

Evidence concerning concussion education content and strategies has dramatically improved in recent years, with the authors of several studies evaluating factors to be addressed and effective methods of education. Additionally, the roles of several key stakeholders and the need for interprofessional communication and collaboration that can inform educational content and strategies have been clarified.⁴⁰  These stakeholders include but are not limited to athletes, coaches, parents, school administrators, student resources personnel, and organizational management teams.⁴⁰ 

One important area of education is the unchallengeable authority of licensed medical personnel in the medical decision-making processes that accompany concussion care as well as return to activity after concussion. Consensus bodies indicated the need for this model of care to reduce conflicts of interest and improve the care and well-being of athletes.⁴¹  All key stakeholders are encouraged to receive comprehensive concussion education, including the topic of medical authority and factors that may be specific to their local context, such as the organization or institution's resources, infrastructure, and location. Athletes should also be informed about their roles as both individuals and teammates in assisting in the identification of SRC.³²  These stakeholders may be engaged in education through preseason meetings, incorporating activities across the season, or more regularly than only at the beginning of the year.³²  In addition to more traditional educational strategies, social media and other electronic means should be employed.

Beyond the typical education concerning prevention, recognition, management, and treatment of SRC, stakeholder education may include the ramifications of driving any vehicle or riding a bicycle, during which they are expected to obey traffic laws, while recovering from the injury.^8,20,32–37  Although ATs do not conduct full driving assessments, understanding the athlete’s state and recovery process is important when ATs discuss these concerns with the physician or other concussion care team members. When patients are symptomatic or demonstrate functional impairments, ATs may recommend alternative transportation (eg, carpooling and public transport). To better understand the athlete’s recovery, key stakeholders should be aware of the potential effect of the injury on driving. Researchers have illustrated cognitive deficits and slowed driving reaction time, even after symptom resolution, that may place the athlete, passengers, and others at risk.^33–35,37 

Educational materials and delivery ideally should be environmentally and culturally considerate of the sociocultural factors that may influence concussion perceptions and care among diverse patient populations, consistent with biopsychosocial approaches to concussion care.^25,26  Sociocultural factors and social determinants of health (such as race and socioeconomic status) affect not only concussion education outcomes such as concussion-related knowledge but are associated with clinical outcomes such as neurocognitive and visual-vestibular assessment scores.^{24,25,27,28,42–44}  Additionally, connecting this education to the values (eg, performance, supporting the team) and athletic performance domains is especially important for “buy-in” and effectiveness. Sociocultural factors should be foundational to all areas of educational content and educational strategies.

No changes in guidance surrounding medical documentation and the legal aspects of concussion have ensued since 2014, so Table 2 outlines these items in the 2014 statement. Athletic trainers are encouraged to be aware of the legal ramifications of mismanaging a patient with concussion⁴⁵  and educate themselves on the relevant organizational, state, and local rules and regulations and the need for appropriate documentation throughout the injury and recovery process.

The 2014 statement and current bridge statement assessment recommendations are provided in Table 3.

Substantial changes surrounding the assessment of SRC have occurred in the previous decade. Most of the work has centered on individual assessment tools and the timing of administration; injury heterogeneity and the lack of specificity of several concussion-related symptoms make the assessment and management process uniquely challenging. Thus, a broad approach to injury management under the biopsychosocial model^23,54  can help the clinician separate what is directly related to the injury from factors that influence the injury presentation.

Several structural and situational variables can affect the baseline and postinjury evaluations, rendering implementation of all assessments unnecessary or unfeasible in some situations before or during the injury management process.⁵⁵  Athletic trainers are encouraged to adopt a standardized approach to injury management that uses the tools and procedures specific to their setting, implementing new domains when resources and circumstances allow. Also, mental health screenings should be considered during the concussion management process (see the Mental Health section) with the intent of improving clinical care and outcomes.^46,56  Consistent with prior recommendations, the assessment should include a thorough clinical examination, supported by clinical assessments where available and with the AT’s medical decisions based on the best clinical judgment.

Baseline testing has long been considered an integral component of concussion evaluation, which typically consists of a battery of tests that assess self-reported symptoms and multiple domains of cognitive functioning and motor control (eg, balance). Usually administered in the weeks before the preseason, the baseline assessment is intended to capture normal functioning of the athlete. This snapshot of overall functioning is often used as a reference point against postinjury data to determine when the athlete has returned to the preconcussion level of functioning.^8,36 

Baseline testing need not be an integral part of the concussion management plan unless required by the school, state, sporting association, or other relevant guidelines. Some work suggested that annual assessments are necessary to maximize postinjury evaluations,⁵⁷  but several international groups,³⁶  medical organizations,²⁰  and independent investigations^48,58,59  indicated that annual baseline testing may not be necessary to optimize postinjury care. In the absence of clinical baseline data, the clinical trajectory postinjury (ie, progression through the injury process) can still be a valuable indicator of recovery. Whereas inclusive normative data are available for some evaluation tools, clinicians must account for the individual’s personal and medical history when interpreting manufacturer- or site-specific normative data. If baseline testing is conducted, it is imperative that ATs administer the selected assessments in accordance with testing guidelines, potentially evaluating the athlete’s performance for validity, and repeat testing as necessary. Administering and interpreting tests outside of the recommended guidelines significantly impairs their utility in the postinjury state. It is important to note that the preseason is an optimal time for concussion education, baseline testing if available and indicated, and implementing a positive social environment for athletes regarding concussion reporting.

The evaluation of concussion-related symptoms, neurologic and neurocognitive status, and motor control domains is the core of the concussion assessment process, with emerging evidence suggesting that a vision or vestibulo-ocular examination should inform the AT’s clinical decisions.^{49–51,60,61}  Multiple tests are available to assess each of the primary domains, and clinicians should become familiar with how to best administer each test, the psychometric properties⁴⁷  for test interpretation, and the limitations of each test. The domains outlined in Table 4 supply providers with information to better inform clinical decision-making.

Although concussion assessment via the evaluation of multiple domains (as noted earlier) continues to be endorsed, the limitations of cognitive testing are being identified. Recent work on the most common computer-based cognitive assessments administered in the first 48 hours after injury revealed sensitivities that were only slightly better than chance.⁶²  Other researchers have demonstrated no added benefit of computer-based cognitive testing beyond a symptom evaluation, neurologic examination, and motor control assessment within the first 48 hours of injury.⁵⁷  Mass baseline testing of athletes (when available) is discouraged by the test manufacturers, yet the time constraints and demands of athletic medicine often preclude the ability to administer tests appropriately, affecting their postinjury validity.⁵²  Given the demands, limitations, and practicalities of athletic medicine, cognitive testing should no longer be considered an integral part of the concussion assessment process. Despite this, some may administer these tests as a preseason baseline and postinjury under optimal conditions, ie, when the appropriate time, equipment, and trained personnel are available, in special circumstances (eg, with persisting symptoms), or at the discretion of the directing physician. Additionally, the key domains of the baseline and postinjury concussion assessment can be conducted in the absence of computerized testing, allowing for a more inclusive assessment approach that relies less heavily on facilities and resources.

Consistent with previous recommendations, from the moment of a suspected injury through all evaluations, the clinical examination remains the criterion standard for decision-making, with support from adjunct assessments when available.⁸  At the discretion of the AT, the postinjury examination may include the domains listed in Table 4^8,20,53,63  or other measures deemed relevant. The importance of cervical injury in the signs and symptoms after concussion has been recognized.^64–68  Authors of studies in other areas of traumatic brain injury have suggested cervical dysfunction may be correlated with longer recovery times and additional postinjury deficits. Specifically, a complete cervical spine evaluation⁶⁹  should be conducted initially to rule out any cervical injuries, including more severe injuries, and may be repeated during follow-up to identify any problems that may require treatment and affect the outcome.

Previous recommendations highlighted the need to assess all domains at all time points throughout the recovery process.⁸  However, in many cases, concussion is obvious without having to assess all domains. Such instances may include but are not limited to an observed injury mechanism with altered consciousness or gross motor impairment (or both) or symptom reports consistent with concussion the day after injury.⁷⁰  Furthermore, some assessment tools have greater or lesser utility throughout the management process. For example, the Standardized Assessment of Concussion has the greatest utility within 48 hours of injury but lacks the requisite sensitivity to be beneficial beyond that time frame.^71–73 

Athletic trainers are obligated to abide by policies and procedures consistent with external mandates from sports organizations, state legislations, or similar entities, but concussion policies should empower them to use their clinical judgment in selecting and implementing the specific assessments needed to facilitate clinical care.⁵⁷  Athletic trainers should apply their best clinical judgment in conducting the examination, including which domains are to be evaluated, which assessments are implemented to evaluate the chosen domains, and how to weigh the clinical importance of the findings in the best interests of the patient. Simply stated, the AT must maintain legal compliance but is not bound to complete all assessments at all timepoints. Moreover, ATs and other appropriately trained medical personnel should hold unchallengeable authority over nonmedical providers to remove and withhold those athletes with a suspected concussion from participation.^38,39 

Recommendations for prognostic factors concerning recovery and persisting symptoms are shown in Table 5.

As outlined in the 2014 NATA position statement and recent literature, several factors may modify the management, return-to-play, and other outcomes postconcussion.^8,74–76  Over the past 5 years, several groups have evaluated prognostic signs and symptoms, including potential clinical subtypes associated with recovery, with various levels of evidence as described by Iverson et al⁷⁰  in a comprehensive review.^74,77–80  The most recent updates support the concept that the initial symptom burden is closely associated with recovery time (ie, those with a higher initial burden take longer to recover).^81–83  Additionally, authors of prospective and retrospective studies have indicated that early care seeking, both in the clinic and on-field, facilitated recovery and improved the return to play, whereas delayed medical evaluation may delay recovery.^84–87  Investigators who study attention-deficit/hyperactivity disorder now believe it to be a risk factor for sustaining a concussion but have questioned its relationship to delayed recovery.^80,88,89  New data suggest that visual-vestibular deficits postconcussion influence the recovery time. More context concerning factors that may influence injury recovery is supplied in Table 6.^8,74,88  The literature surrounding the social determinants of health concerning concussion is evolving,^25–28  yet evidence from various disciplines emphasizes the need to consider the social and cultural factors that may influence patients’ outcomes, health care delivery, and health care overall.^85,86 

The current bridge statement mental health recommendations are shown in Table 7. The 2014 statement contained no recommendations in this area.

The mental health of patients before and after sport-related injury has drawn increasing attention from sport governing bodies¹⁰¹  and medical organizations. Guidelines and recommendations for improving mental health services planning have been published.^46,56,102  Organizations are advised to have plans for emergent mental health referrals, to educate clinicians on the appropriate monitoring of behavior for psychological concerns, and to have procedures in place for the referral of student-athletes with psychological concerns. Athletic trainers should be aware of these recommendations and develop mental health policies and procedures to include collaborative partners for referring patients with mental health considerations. Such considerations are especially important in SRC, as preexisting mental health conditions can influence the baseline and postinjury assessments, are often exacerbated after injury, and can influence the symptom presentation and length of recovery.

Screening for mental health conditions before sport participation is important for several areas of concussion management, including the interpretation of adjunct assessments and the prognosis postconcussion.¹⁰³  With respect to preparticipation screening, the most recent iteration of the preparticipation monograph¹⁰⁴  includes a robust chapter on mental health. The revised preparticipation screening history form uses the Patient Health Questionnaire-4 (PHQ-4) to screen for anxiety and depression, and the physical examination form reminds providers to ask mental health–related questions.¹⁰⁴  The slightly longer PHQ-9 could be a valid screening tool as part of the preseason intake forms or for patients after concussion in the presence of mental health concerns. Furthermore, interassociation recommendations^46,56  offer clinicians a list of behaviors to monitor in student-athletes, and other authors^92,98,105  have summarized various patient-reported outcome measures that can assist in screening athletes for mental health conditions.

Identifying patients with a history of mood disorders is important for the appropriate interpretation of adjunct concussion assessments used at baseline or postinjury.⁹⁸  Athletes with preexisting mental health conditions have consistently demonstrated higher symptom scores at baseline than athletes without preexisting conditions,^106–109  whereas differences among balance and neurocognitive assessments have been inconsistent. Also, a history of concussion has been associated with reports of worse psychological health and quality of life.^93–96  Specifically, youth athletes with a history of ≥1 concussions displayed more perceptions of psychiatric difficulties,⁹³  and adolescent⁹⁵  and collegiate⁹⁶  athletes with concussion histories reported poorer general health, vitality, social functioning, and mental health. Chrisman et al⁹⁶  noted that adolescents with a concussion history were at a 3.3 times greater risk for depression, and Sarmiento et al¹¹⁰  found that adolescents with ≥1 concussions more often (41%) expressed persistent feelings of sadness or hopelessness.

Concussion may also result in postinjury mental health difficulties, including a few symptoms that may be categorized as an emotional or affective cluster,¹¹¹  which may represent either an exacerbation of a prior condition or the emergence of new symptoms. Several investigators have noted transient mood disturbances and lower health-related quality of life after concussion that typically resolved as the patient recovered and returned to school, social, and sport activities.^112–114  In some cases, however, the recovery from mood disturbances may not follow the recovery trajectory of other concussion domains. This should raise suspicion of an underlying mood disorder and prompt a thorough clinical examination.²⁰  The use of patient-reported outcome measures (Table 8) may help clinicians better understand the effect of specific symptoms endorsed by patients on the traditional graded symptom scale indicating the perception of their health.^98,115  Clinicians using patient-reported outcome measures should be familiar with their administration, scoring, and interpretation. Furthermore, a mental health policy and procedures document should be in place to provide guidance for any test scores that exceed established cutoffs or responses that are concerning to the clinician.^67,68 

For patients with diagnosed mental health conditions, the evidence suggests their preexisting conditions may influence concussion recovery and should be included as part of the postconcussion patient education discussion. In 9 of 12 studies in a recent systematic review,⁹⁷  a psychiatric history increased the risk of persisting symptoms. In other research outlined in this review, an association was identified between a family history of psychological illness and worse postinjury outcomes, including persisting symptoms. In their systematic review, Rice et al¹¹⁶  noted an association with depression in both those acutely postconcussion and those with persisting symptoms. The association between concussion and other mental health conditions, such as anxiety and other mood disorders, was inconsistent or limited.¹¹⁶  These findings support the use of a biopsychosocial model and patient-reported outcomes for assessing and managing patients with concussion.^23,98,117 

Studies of long-term mental health conditions after concussion are often limited by design and recall bias. In a systematic review of long-term health considerations after concussion, Manley et al⁷⁵  determined that psychological health problems existed in only a minority of former professional American football athletes. Among those reporting mental health conditions, depression was the most common, and current depression was more prevalent in those with a history of concussion.⁷⁵  Similarly, a history of concussion was consistently associated with a clinical depression diagnosis and depressive symptom acknowledgment among former athletes, even when accounting for confounding factors.¹¹⁸ 

Preexisting mental health conditions or postconcussion mood and anxiety symptoms can complicate concussion management, so ATs are encouraged to include assessments to help identify these concerns and have mental health referral networks in place in their concussion protocols. To ensure proper recognition and referral of patients with mental health conditions after concussion, ATs should develop a plan that follows the guidance provided by the twin Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns statements.^46,56  Seeking local referral sources with expertise in mental health conditions, including psychologists, school psychologists, neuropsychologists, psychiatrists, or school counselors, is an important part of the recommendations and allows the AT to have collaborators in position before they are needed for the referral of a specific patient.⁹²  Establishing these lines of communication with other health care providers in advance can assist in educating patients and families after the injury and aid in timely referrals when required.

The 2014 statement and the current bridge statement recommendations on cognitive activity and return to school are outlined in Table 9.

Supporting student-athletes as they return to school is an important aspect of concussion management. Numerous symptoms associated with concussion can hinder a student-athlete’s ability to succeed in the classroom.¹²⁶  Therefore, individualized monitoring of postconcussion symptoms and the implementation of return-to-school plans can create an optimal environment for returning to academics.¹⁸  Authors have evaluated aspects of returning to academics among secondary school students, yet the evidence for college and elementary school students is limited. The most recent international Concussion in Sport Group statement recommended that children and adolescents not be cleared for a full return to competition until they have successfully completed a full return to school.¹⁹  However, instituting the return-to-school and return-to-play progressions in parallel¹²⁴  may improve outcomes versus prolonged strict cognitive and physical rest.¹²⁷ 

Successful return to school may require academic support, including a brief absence from school, as the heightened symptomatic state after concussion may cause cognitive difficulties that interfere with the ability to keep up with academic requirements.¹²⁵  Current guidelines caution against returning students immediately to school, but this does not mean that they should remain at home for an extended period of time.¹⁸  Evidence from 2 systematic reviews suggested that, although an initial short period of relative rest (eg, 24 to 48 hours) is beneficial, beginning subsymptom threshold-limited physical and cognitive exertion after this timeframe improves outcomes.^127,128 

At both the secondary school^129,130  and collegiate levels,¹³¹  ATs and the school-based concussion management team could improve their familiarity with academic supports and the facilitation of an athlete’s return to academics. The AT, who is often the first person the student-athlete sees for concussion management, plays a critical role in supporting student-athletes as they progress through the return-to-school plan.^129,131  Practical implementation of academic supports requires an interdisciplinary school-based concussion management team, with involvement and home monitoring from the family.^{18,119,122,126}  Team members and stakeholders with academic responsibilities on the concussion management team can include health care providers, school personnel and administrators, the student-athlete, and the student-athlete’s family members.^18,122,126  Nearly 75% of ATs surveyed said they should be a part of the academic support team^129,132 ; inconsistencies existed regarding their roles in the development and implementation of academic supports.^100,133  These inconsistencies were primarily influenced by the school’s infrastructure, the ATs’ knowledge of academic supports, and the ATs’ perceptions of their role at the school. Those ATs with involvement in supplying academic support identified several strategies to successfully implement academic adjustments, including the establishment of a formal policy, development of individualized return-to-learn (RTL) progressions, and use of a multidisciplinary concussion management team.¹³⁴  Because the role of the AT in the concussion management team is often school dependent, each AT should be involved in discussions regarding the role of each of the concussion management team members in developing the concussion policy. One component of this policy is to educate all team members and stakeholders on how a concussion can affect learning so that they may improve care and support for any academic challenges, reduce the effect of symptoms on learning, and help ensure a successful transition back to the classroom.^18,122,126 

Heavy academic loads that may cause significant difficulties in school postconcussion can be mitigated through various academic supports.^99,126  Academic supports include a range of options such as temporary academic adjustments (eg, extra time, reduced load), formal accommodations (eg, 504 plan), and academic modifications (eg, Individualized Education Program [IEP]).¹¹⁹  It is vital for ATs to become familiar with the different levels of academic supports available and the process for implementing these supports in their institution or school district, even if they are not the primary initiators. Most patients require only temporary academic adjustments, such as wearing sunglasses and sitting away from bright sunlight or other noxious classroom lighting for patients with light sensitivity, that can be offered by teachers and the concussion management team.¹¹⁹  Iverson et al recommended several areas of adjustment based on the patient’s presentation. For example, shorter assignments and a lighter workload could be given to patients presenting with attention, concentration, or memory deficits or hall passes and rest breaks to patients with complaints of headache or dizziness.¹²⁶  Regarding informal academic adjustments, the AT plays a crucial role in informing the school-based team of the patient’s current symptom status and physical deficits so that specific academic adjustments can be developed. Formal accommodations include Individualized Healthcare Plans, Section 504 plans, or IEPs for patients with persisting symptoms or significant impairments after concussion.¹¹⁹  A health care provider can ask a school to consider a 504 plan or IEP for a student postconcussion but cannot prescribe such plans. The decision is made after a school-based multidisciplinary evaluation.^18,119  Understanding and implementing a safe return to academics through interprofessional collaboration and proper concussion management will ultimately assist the student-athlete’s academic, emotional, and physical recovery.¹²³  In these situations involving more formal academic support, the AT may function as part of the team developing the supports, contributing important health information on the patient’s symptom status over time, and identifying deficits on physical or cognitive testing. (A detailed RTL progression is illustrated in Table 10.) It should be noted that not all students require academic supports; those who do may not need to begin at stage 0, and many will not have any school absences. The entry point for the RTL progression should be dictated by the patient’s symptoms and functional status in collaboration with medical and school personnel.^19,120 

The 2014 statement and the current bridge statement recommendations on physical activity, rehabilitation, and return to sport are offered in Table 11.

Despite previous clinical guidelines that endorsed strict cognitive and physical rest as a primary treatment for concussion, recent randomized controlled trials suggested that an immediate initial period of relative rest (24 to 48 hours) followed by symptom-limited cognitive and physical activity as well as symptom-tolerated aerobic exercise treatment and clinician-directed activities may be appropriate.^{12,14,15,121,135,136}  Earlier return-to-play protocols were crafted primarily for the contact- or collision-sport athlete and did not consider the unique demands of noncontact-sport athletes with concussion. When managing athletes with concussion, ATs should help them steadily increase aerobic exercise duration and intensity, avoiding more than a mild increase in symptoms (mild = ≤2-point increase in any symptom during activity or exercise compared with the preactivity value on a 0–10 scale), before returning them to unrestricted practice and competition.^{12,14,15,19,136,137,140}  The updated return-to-sport protocol is available in Table 12. The most current literature highlighted the negative aspects of strict rest (ie, cocooning). It is now established level 1 evidence that clinically directed physical activity, including prescribed aerobic exercise treatment (based on the individual’s exercise tolerance on systematic exertional testing) that does not exacerbate symptoms more than mildly, facilitates recovery from SRC and reduces the incidence of delayed recovery in adolescent athletes.^{12,14,15,135–137}  Aerobic exercise likely improves autonomic function and oxygen delivery to the brain, yet more studies are needed to fully understand the mechanisms behind the beneficial effects of aerobic exercise on concussion recovery.

The latest evidence on the timing and effectiveness of aerobic activity after SRC indicates that early aerobic activity can facilitate recovery; therefore, it is a recommended portion of the first 2 stages of the return-to-sport strategy. The updated return-to-sport guidance includes clinically directed or supervised aerobic exercise and other interventions as treatment for the injury.^14,138  These are progressed in duration and intensity as an individual moves through the protocol. Authors of prospective studies^{14,15,135,141}  have confirmed that early, controlled subsymptom threshold aerobic exercise was safe and beneficial beginning as soon as 1 to 2 days after injury in symptomatic patients and certainly within the first 10 days after injury.¹³⁷  Additionally, in multiple prospective studies,^{14,15,135,141}  investigators have demonstrated that mild symptom exacerbation during physical activity or exercise did not delay concussion recovery. However, activity that more than mildly exacerbates symptoms, especially if performed repeatedly, may put the athlete at risk for prolonged symptoms and delayed recovery; thus, clinician monitoring of interventions is advised.¹⁴²  Exercise subacutely (within the first 10 days of injury) has proven effective in speeding recovery from concussion in adolescents and reducing their incidence of persisting symptoms (symptoms >1 month).¹⁵  Specifically, individualized subsymptom-threshold aerobic exercise treatment prescribed to adolescent athletes with concussion symptoms as soon as 2 days after SRC safely sped up recovery and reduced the incidence of delayed recovery.^14,15,135 

Evidence also supports the use of aerobic exercise and deficit-targeted rehabilitation interventions to improve outcomes in individuals with prolonged symptoms.^12,138,139  Exercise and targeted rehabilitation strategies can be safely implemented in both the early and late phases of the concussion recovery process. Vestibular^143,144  and cervicovestibular rehabilitation protocols^{138,139,145–147}  have been successfully and safely performed by individuals with persisting symptoms. Patients who received these directed therapies displayed faster recovery and improved outcomes when compared with those who did not receive them.^{12,13,137,138} 

No change in guidance surrounding equipment has occurred since the 2014 position statement. As such, no background is presented for this section. All ATs should continue to be aware of new equipment and critically appraise its validity before implementation. Table 13 supplies the 2014 recommendations.

Since the publication of the 2014 NATA position statement on concussion management, the science and care of individuals with concussion have advanced significantly. Despite these improvements, concussion remains one of the most complex and challenging injuries for the practicing AT to manage. The present bridge document, which synthesizes key literature over the previous decade, supplements the 2014 statement by presenting new or modified recommendations that link the existing position statement to the best current clinical evidence by giving foundational information for the AT concerning the assessment and management of the patient with concussive injury. Important updates include the education of patients about driving, use of vision or vestibulo-ocular assessments, assessment timing and domains, considerations in evaluating and addressing mental health concerns, management of return to academics, identification of prognostic factors for prolonged recovery, and active treatment and rehabilitation strategies for those with acute concussions and those with persisting symptoms. In addition to reflecting on updated evidence in the clinical management of concussion, this bridge document highlights the need to adopt the biopsychosocial model for managing concussion, which emphasizes the social and cultural factors affecting quality of care and patient outcomes.

The new and revised recommendations integrate known evidence into areas with large effects on clinical practice for ATs involved in a team-based approach to concussion management. To effectively implement the new evidence in a manner that maximizes patient care, ATs are encouraged to facilitate interprofessional care by engaging with domain-specific stakeholders who have expertise beyond the scope of AT clinical practice when feasible. Despite the updates provided herein, concussion science and care will continue to evolve, including in the areas of diagnostic and treatment capabilities. To best facilitate a successful outcome for their patients, ATs are encouraged to stay abreast of scientific advances and thoughtfully modify clinical policies within their scope of practice to provide evidence-based care whenever possible.

We gratefully recognize the authors of the previous position statement for providing a foundation to this work, the Pronouncements Committee for its guidance, and the practicing ATs who work tirelessly to improve the health and safety of those under their care. We also thank Scott L. Bruce, EdD, ATC; Thomas A. Buckley, EdD, ATC; and Jane K. McDevitt, PhD, ATC, CSCS, for their assistance.

Steven P. Broglio, PhD, ATC, has current or past research funding from the Centers for Disease Control and Prevention, the Department of Defense–USA Medical Research Acquisition Activity, ElmindA, the NATA Foundation, the National Collegiate Athletic Association, National Football League/Under Armour/GE, the National Institutes of Health, and Simbex. He is coauthor of Biomechanics of Injury (third edition, Human Kinetics; 2023) and has consulted for US Soccer (paid), US Cycling (unpaid), and medico-legal litigation and received speaker honoraria and travel reimbursements for talks given. He has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (US Application No. 17/164,490). He is on the University of Calgary SHRed Concussions External Advisory Board (unpaid) and is or was on the editorial board (all unpaid) for Athletic Training & Sports Health Care (2008 to present), the British Journal of Sports Medicine (2008 to 2019), and Concussion (2014 to present) and is an Associate Editor for the Journal of Athletic Training (2012 to present).

Johna K. Register-Mihalik, PhD, ATC, reports grants from the Centers for Disease Control and Prevention/National Center for Injury Prevention and Control, the NATA Foundation, the National Collegiate Athletic Association–Department of Defense Mind Matters Research Challenge Award, the National Football League, the National Operating Committee on Standards for Athletic Equipment, and the US Department of Defense outside the submitted work. She is a prior member of USA Football’s Football Development Council and a current member of USA Football’s Girls Football Council. Dr Register-Mihalik’s spouse is also a partner/chief science officer in a sports vision company, Senaptec (not discussed in this statement). She has received speaker and travel honoraria for talks given.

Kevin M. Guskiewicz, PhD, ATC, reports grants from the National Collegiate Athletic Association, the National Collegiate Athletic Association–Department of Defense Concussion Assessment, Research and Education Consortium, and the National Football League. He is also a member of the National Collegiate Athletic Association Scientific Advisory Committee.

John J. Leddy, MD, reports grants from the American Medical Society for Sports Medicine, the National Institutes of Health, the National Institutes of Health Clinical and Translational Science Awards Program, and the US Department of Defense. He is a member of the Scientific Advisory Board for Highmark Innovations and Neuronasal and holds stock options in Highmark Innovations and 360 Concussion Care.

Tamara C. Valovich McLeod, PhD, ATC, reports prior grant funding from the Headache Foundation, the National Operating Committee on Standards for Athletic Equipment, and the NATA Foundation outside the submitted work. She is a member of the National Football League’s Head, Neck, and Spine Committee.

The NATA and NATA Foundation publish position statements as a service to promote the awareness of certain issues to their members. The information contained in the position statement is neither exhaustive nor exclusive to all circumstances or individuals. Variables such as institutional human resource guidelines, state or federal statutes, rules, or regulations, as well as regional environmental conditions, may impact the relevance and implementation of these recommendations. The NATA and NATA Foundation advise members and others to consider carefully and independently each of the recommendations (including the applicability of same to any particular circumstance or individual). The position statement should not be relied upon as an independent basis for care but rather as a resource available to NATA members or others. Moreover, no opinion is expressed herein regarding the quality of care that adheres to or differs from the NATA and NATA Foundation position statements. The NATA and NATA Foundation reserve the right to rescind or modify its position statements at any time.