Objective

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers’ Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

Background

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

Recommendations

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

Over the previous decade, athletic training and other medical researchers have made a myriad of scientific gains in the prevention, assessment, management, and treatment of concussion. Despite substantial advances in the science, sport-related concussion (SRC) continues to be a serious concern at all levels of sport. During the last decade and a half, the number of concussions noted in epidemiologic studies has increased significantly, likely resulting from heightened awareness among the public and medical personnel, improved recognition and reporting, and updates to legislation and management policy.1–3  An estimated 1.1 million to 1.9 million SRCs occur annually in those under 18 years of age in the United States.4  At the collegiate level, approximately 10 560 concussions occur each year, accounting for approximately 6% of all sport-related injuries.5  At the professional sports level, data from the National Football League indicated a 5-year concussion rate of 1.70 concussions per 10 000 player-plays and an overall risk of concussion of 7.4%.6  Concussion also remains a significant injury among the general physically active population, accounting for close to half a million US emergency department visits annually and 7% of sport-related emergency department visits across all ages.1 

As part of an interdisciplinary medical team, athletic trainers (ATs) regularly identify and manage patients with concussion using guidance in concussion management stemming from the 2 previous NATA position statements.7,8  Substantial improvements in concussion care have been noted since the initial statement was published in 2004, with more recent data suggesting that patients should remain out of participation longer, which has reduced the risk of repeat injuries.9  Additionally, ATs appear to be using concussion assessment and return-to-activity protocols consistent with published recommendations at a higher rate than shown in past practice surveys.10 

The most recent NATA position statement on SRC is a decade old, and considerable knowledge gains in the medical literature warrant updating several recommendations. Notably, emerging advances in concussion management and treatment have resulted in improved patient outcomes,11–13  including quicker symptom resolution and return to activity among patients engaged in early aerobic exercise14,15  as well as improved balance and reduced dizziness among patients who completed vestibular rehabilitation.16  However, ATs may be restricted in their ability to implement scientific gains due to policies drafted based on the prior NATA position statements and similar documents that reflect outdated knowledge.

Regardless of their clinical setting, ATs, in collaboration with their directing physicians, are encouraged to apply concussion management approaches that incorporate the most up-to-date scientific literature to support their patients’ best interests while practicing within the scope of their state practice acts and state concussion laws. This includes viewing concussion through a biopsychosocial model, which lays the foundation for managing each patient individually and is supported by recent consensus statements,17–19  position statements,20  and theoretical papers.21–23  The biopsychosocial model encompasses both biological (preinjury burden, trauma burden biomarkers) and psychosocial (psychological functioning, social and physical environmental factors, motivational factors) aspects of the patient and injury. Both the biological and psychosocial elements are important for determining the effects of the concussion on patient outcomes, including neurologic health, neurocognitive functioning, neurobehavioral function, psychosocial health and wellness, and life function and quality.21–23  Social determinants of health24–28  as well as culturally safe and competent care must also be considered across the concussion care continuum, from preseason assessments to full recovery and beyond,29,30  given their influences on the quality of care and patient outcomes.

This publication is not intended as a full position statement or exhaustive systematic review but as a document to bridge the gap between the 2014 position statement and the current state of concussion evidence based on the published literature between 2014 and 2023, recommendations from other organizations, and discrepancies between clinical practice and policies stemming from older documents.

The literature review was conducted by the authorship team and was based on areas with clinical advancements relevant to ATs. The evidence and recommendations are presented using the Strength of Recommendation Taxonomy (SORT) framework as described in previous publications by the NATA.31  Despite the updated recommendations in this document, concussion science continues to evolve, and medical care will improve in the years to come. In conjunction with their supervising physicians, ATs have a responsibility to implement the most cutting-edge, peer-reviewed evidence that is in the best interests of their patients.

Therefore, the purpose of this document is to provide ATs and team physicians with updated recommendations based on the state of concussion evidence in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport using the biopsychosocial model and consideration for the social determinants of health as the underlying framework. Clinicians should refer to the 2014 position statement for the recommendations that have not been revised and the background literature supporting those recommendations. Tables associated with each section align the 2014 recommendations with the current 2024 bridge statement updates for ease of review.

Recommendations

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

Table 1.

Recommendations for Education and Prevention

Recommendations for Education and Prevention
Recommendations for Education and Prevention

Background and Supporting Literature

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.

Recommendations

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.

Table 2.

Documentation and Legal Aspects Recommendations

Documentation and Legal Aspects Recommendations
Documentation and Legal Aspects Recommendations

Recommendations

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

Table 3.

Recommendations for Assessment Advances

Recommendations for Assessment Advances
Recommendations for Assessment Advances

Background and Supporting Literature

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 model23,54  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

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 investigations48,58,59  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.

Assessment Domains

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.

Table 4.

Assessment Domains

Assessment Domains
Assessment Domains

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 persistent 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.

Postinjury Testing

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 48,20,53,63  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

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

Table 5.

Recommendations for Prognostic Factors for Recovery and Persistent Symptoms

Recommendations for Prognostic Factors for Recovery and Persistent Symptoms
Recommendations for Prognostic Factors for Recovery and Persistent Symptoms

Background and Supporting Literature

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 

Table 6.

Risk Factors for Delayed or Difficult Recovery Consistent in the Literature

Risk Factors for Delayed or Difficult Recovery Consistent in the Literature
Risk Factors for Delayed or Difficult Recovery Consistent in the Literature

Recommendations

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

Table 7.

Recommendations for Mental Health

Recommendations for Mental Health
Recommendations for Mental Health

Background and Supporting Literature

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 recommendations46,56  offer clinicians a list of behaviors to monitor in student-athletes, and other authors92,98,105  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 

Table 8.

Patient-Reported Outcome Measures for Mental Health Conditions

Patient-Reported Outcome Measures for Mental Health Conditions
Patient-Reported Outcome Measures for Mental Health Conditions

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 persistent symptoms. In other research outlined in this review, an association was identified between a family history of psychological illness and worse postinjury outcomes, including persistent symptoms. In their systematic review, Rice et al116  noted an association with depression in both those acutely postconcussion and those with persistent 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.

Recommendations

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

Table 9.

Recommendations for Cognitive Activity and Return to School

Recommendations for Cognitive Activity and Return to School
Recommendations for Cognitive Activity and Return to School

Background and Supporting Literature

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 school129,130  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 team129,132 ; 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 persistent 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 

Table 10.

Return-to-Academics Strategya

Return-to-Academics Strategya
Return-to-Academics Strategya

Recommendations

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

Table 11

Physical Activity, Rehabilitation, and Return-to-Sport Recommendations

Physical Activity, Rehabilitation, and Return-to-Sport Recommendations
Physical Activity, Rehabilitation, and Return-to-Sport Recommendations

Background and Supporting Literature

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.

Table 12.

Return-to-Play or -Sport Strategya

Return-to-Play or -Sport Strategya
Return-to-Play or -Sport Strategya

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 studies14,15,135,141  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 persistent 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. Vestibular143,144  and cervicovestibular rehabilitation protocols138,139,145–147  have been successfully and safely performed by individuals with persistent 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 

Recommendations

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.

Table 13.

Equipment Recommendations

Equipment Recommendations
Equipment 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 persistent 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.

1.
Coronado
VG,
Haileyesus
T,
Cheng
TA,
et al
Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001–2012
.
J Head Trauma Rehabil
.
2015
;
30
(
3
):
185
197
.
2.
Gibson
TB,
Herring
SA,
Kutcher
JS,
Broglio
SP.
Analyzing the effect of state legislation on health care utilization for children with concussion
.
JAMA Pediatr
.
2015
;
169
(
2
):
163
168
.
3.
Yang
J,
Comstock
RD,
Yi
H,
Harvey
HH,
Xun
P.
New and recurrent concussions in high-school athletes before and after traumatic brain injury laws, 2005–2016
.
Am J Public Health
.
2017
;
107
(
12
):
1916
1922
.
4.
Bryan
MA,
Rowhani-Rahbar
A,
Comstock
RD,
Rivara
F;
Seattle Sports Concussion Research Collaborative
.
Sports- and recreation-related concussions in US youth
.
Pediatrics
.
2016
;
138
(
1
):
e20154635
.
5.
Zuckerman
SL,
Kerr
ZY,
Yengo-Kahn
A,
Wasserman
E,
Covassin
T,
Solomon
GS.
Epidemiology of sports-related concussion in NCAA athletes from 2009–2010 to 2013–2014: incidence, recurrence, and mechanisms
.
Am J Sports Med
.
2015
;
43
(
11
):
2654
2662
.
6.
Mack
CD,
Solomon
G,
Covassin
T,
Theodore
N,
Cárdenas
J,
Sills
A.
Epidemiology of concussion in the National Football League, 2015–2019
.
Sports Health
.
2021
;
13
(
5
):
423
430
.
7.
Guskiewicz
KM,
Bruce
SL,
Cantu
RC,
et al
National Athletic Trainers’ Association pronouncement committee: position statement on sport-related concussion
.
J Athl Train
.
2004
;
39
(
3
):
280
297
.
8.
Broglio
SP,
Cantu
RC,
Gioia
GA,
et al
;
National Athletic Trainers’ Association. National Athletic Trainers’ Association position statement: management of sport concussion
.
J Athl Train
.
2014
;
49
(
2
):
245
265
.
9.
McCrea
M,
Broglio
S,
McAllister
T,
et al;
CARE Consortium Investigators
.
Return to play and risk of repeat concussion in collegiate football players: comparative analysis from the NCAA Concussion Study (1999–2001) and CARE Consortium (2014–2017)
.
Br J Sports Med
.
2020
;
54
(
2
):
102
109
.
10.
Lempke
LB,
Schmidt
JD,
Lynall
RC.
Athletic trainers’ concussion-assessment and concussion-management practices: an update
.
J Athl Train
.
2020
;
55
(
1
):
17
26
.
11.
Thomas
RE,
Alves
J,
Vaska Mlis
MM,
Magalhaes
R.
Therapy and rehabilitation of mild brain injury/concussion: systematic review
.
Restor Neurol Neurosci
.
2017
;
35
(
6
):
643
666
.
12.
Carter
KM,
Pauhl
AN,
Christie
AD.
The role of active rehabilitation in concussion management: a systematic review and meta-analysis
.
Med Sci Sports Exerc
.
2021
;
53
(
9
):
1835
1845
.
13.
Haider
MN,
Bezherano
I,
Wertheimer
A,
et al
Exercise for sport-related concussion and persistent postconcussive symptoms
.
Sports Health
.
2021
;
13
(
2
):
154
160
.
14.
Leddy
JJ,
Haider
MN,
Ellis
MJ,
et al
Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial
.
JAMA Pediatr
.
2019
;
173
(
4
):
319
325
.
15.
Leddy
JJ,
Master
CL,
Mannix
R,
et al
Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial
.
Lancet Child Adolesc Health
.
2021
;
5
(
11
):
792
799
.
16.
Alsalaheen
BA,
Mucha
A,
Morris
LO,
et al
Vestibular rehabilitation for dizziness and balance disorders after concussion
.
J Neurol Phys Ther
.
2010
;
34
(
2
):
87
93
.
17.
McCrory
P,
Meeuwisse
W,
Dvořák
J,
et al
Consensus statement on concussion in sport-the 5th International Conference on Concussion in Sport held in Berlin, October 2016
.
Br J Sports Med
.
2017
;
51
(
11
):
838
847
.
18.
McAvoy
K,
Eagan-Johnson
B,
Dymacek
R,
Hooper
S,
McCart
M,
Tyler
J.
Establishing consensus for essential elements in returning to learn following a concussion
.
J Sch Health
.
2020
;
90
(
11
):
849
858
.
19.
Patricios
JS,
Schneider
KJ,
Dvorak
J,
et al
Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022
.
Br J Sports Med
.
2023
;
57
(
11
):
695
711
.
20.
Harmon
KG,
Clugston
JR,
Dec
K,
et al
American Medical Society for Sports Medicine position statement on concussion in sport
.
Br J Sports Med
.
2019
;
53
(
4
):
213
225
.
21.
Gagnon
I.
Determining outcome in children and adolescents after concussion: viewing things more holistically
.
J Orthop Sports Phys Ther
.
2019
;
49
(
11
):
855
863
.
22.
Kenzie
ES,
Parks
EL,
Bigler
ED,
Lim
MM,
Chesnutt
JC,
Wakeland
W.
Concussion as a multi-scale complex system: an interdisciplinary synthesis of current knowledge
.
Front Neurol
.
2017
;
8
:
513
.
23.
Register-Mihalik
JK,
DeFreese
JD,
Callahan
CE,
Carneiro
K.
Utilizing the biopsychosocial model in concussion treatment: post-traumatic headache and beyond
.
Curr Pain Headache Rep
.
2020
;
24
(
8
):
44
.
24.
Wallace
J,
Beidler
E,
Covassin
T,
Hibbler
T,
Schatz
P.
Understanding racial differences in computerized neurocognitive test performance and symptom-reporting to deliver culturally competent patient-centered care for sport-related concussion
.
Appl Neuropsychol Adult
.
2023
;
30
(
1
):
91
100
.
25.
Wallace
J,
Beidler
E,
Kerr
ZY,
Hibbler
T,
Anderson
M,
Register-Mihalik
JK.
Assessing differences in concussion symptom knowledge and sources of information among black and white collegiate-athletes
.
J Head Trauma Rehabil
.
2021
;
36
(
3
):
139
148
.
26.
Wallace
J,
Beidler
E,
Register-Mihalik
JK,
et al
Examining concussion nondisclosure in college athletes using a health disparities framework and appreciation for social determinants of health
.
J Athl Train
.
2022
;
57
(
1
):
16
24
.
27.
Wallace
J,
Worts
P,
Moran
R,
et al
Socioeconomic status and race as social determinants of health to be considered in clinical use of pre-season vestibular and oculomotor tests for concussion
.
J Clin Transl Res
.
2020
;
6
(
4
):
168
178
.
28.
Wallace
JS,
Mannix
RC.
Racial disparities in diagnosis of concussion and minor head trauma and mechanism of injury in pediatric patients visiting the emergency department
.
J Pediatr
.
2021
;
233
:
249
254.e1
.
29.
Curtis
E,
Jones
R,
Tipene-Leach
D,
et al
Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition
.
Int J Equity Health
.
2019
;
18
(
1
):
174
.
30.
Flynn
PM,
Betancourt
H,
Emerson
ND,
Nunez
EI,
Nance
CM.
Health professional cultural competence reduces the psychological and behavioral impact of negative healthcare encounters
.
Cultur Divers Ethnic Minor Psychol
.
2020
;
26
(
3
):
271
279
.
31.
Ebell
MH,
Siwek
J,
Weiss
BD,
et al
Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature
.
J Am Board Fam Pract
.
2004
;
17
(
1
):
59
67
.
32.
Kroshus
E,
Cameron
KL,
Coatsworth
JD,
et al
Improving concussion education: consensus from the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge
.
Br J Sports Med
.
2020
;
54
(
22
):
1314
1320
.
33.
Schmidt
JD,
Lynall
RC,
Lempke
LB,
Weber
ML,
Devos
H.
Post-concussion driving behaviors and opinions: a survey of collegiate student-athletes
.
J Neurotrauma
.
2018
;
35
(
20
):
2418
2424
.
34.
Schmidt
JD,
Lynall
RC,
Lempke
LB,
Weber
ML,
Devos
H.
Post-concussion driving management among athletic trainers
.
Brain Inj
.
2019
;
33
(
13–14
):
1652
1659
.
35.
Schmidt
JD,
Hoffman
NL,
Ranchet
M,
et al
Driving after concussion: is it safe to drive after symptoms resolve
?
J Neurotrauma
.
2017
;
34
(
8
):
1571
1578
.
36.
McCrory
P,
Meeuwisse
WH,
Dvořák
J,
et al
5th International Conference on Concussion in Sport (Berlin)
.
Br J Sports Med
.
2017
;
51
(
11
):
837
.
37.
Lempke
LB,
Lynall
RC,
Hoffman
NL,
Devos
H,
Schmidt
JD.
Slowed driving-reaction time following concussion-symptom resolution
.
J Sport Health Sci
.
2021
;
10
(
2
):
145
153
.
38.
Courson
R,
Goldenberg
M,
Adams
KG,
et al
Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges
.
J Athl Train
.
2014
;
49
(
1
):
128
137
.
39.
National Athletic Trainers’ Association official statement in support of new NCAA Autonomous 5 (aka Power 5) conferences’ independent medical care rules
.
National Athletic Trainers’ Association
.
Published February
2016
. Accessed April 1, 2021. https://www.nata.org/sites/default/files/power-5-official-statement.pdf
40.
Guskiewicz
K,
Teel
E,
McCrea
M.
Concussion: key stakeholders and multidisciplinary participation in making sports safe
.
Neurosurgery
.
2014
;
75
(
suppl 4
):
S113
S118
.
41.
NCAA Sport Science Institute
.
Interassociation consensus: independent medical care for college student-athletes best practices
. Accessed August 2, 2022. https://ncaaorg.s3.amazonaws.com/ssi
42.
Wallace
J,
Affagato
R,
Brooke
M,
McAllister-Deitrick
J,
Moran
RN,
Covassin
T.
Racial disparities in parent knowledge of concussion and recognition of signs and symptoms
.
J Safety Res
.
2020
;
75
:
166
172
.
43.
Wallace
J,
Moran
R,
Beidler
E,
et al
Disparities on baseline performance using neurocognitive and oculomotor clinical measures of concussion
.
Am J Sports Med
.
2020
;
48
(
11
):
2774
2782
.
44.
Wallace
J,
Hou
BQ,
Hajdu
K,
et al
Health care navigation of Black and White adolescents after sport-related concussion: a path toward health equity
.
J Athl Train
.
2022
;
57
(
4
):
352
359
.
45.
Carroll
MS,
Wieczorek
SH.
Athlete pressured to play through head injury sues football coach and school district
.
Sports Med Leg Digest
.
2018
;
2
(
1
):
8
12
.
46.
Neal
TL,
Diamond
AB,
Goldman
S,
et al
Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement
.
J Athl Train
.
2015
;
50
(
3
):
231
249
.
47.
Portney
LG.
Foundations of Clinical Research: Applications to Practice
. 4th ed.
FA Davis
;
2020
.
48.
Schmidt
JD,
Register-Mihalik
JK,
Mihalik
JP,
Kerr
ZY,
Guskiewicz
KM.
Identifying impairments after concussion: normative data versus individualized baselines
.
Med Sci Sports Exerc
.
2012
;
44
(
9
):
1621
1628
.
49.
Anzalone
AJ,
Blueitt
D,
Case
T,
et al
A positive Vestibular/Ocular Motor Screening (VOMS) is associated with increased recovery time after sports-related concussion in youth and adolescent athletes
.
Am J Sports Med
.
2017
;
45
(
2
):
474
479
.
50.
Knell
G,
Caze
T,
Burkhart
SO.
Evaluation of the vestibular and ocular motor screening (VOMS) as a prognostic tool for protracted recovery following paediatric sports-related concussion
.
BMJ Open Sport Exerc Med
.
2021
;
7
(
1
):
e000970
.
51.
Master
CL,
Master
SR,
Wiebe
DJ,
et al
Vision and vestibular system dysfunction predicts prolonged concussion recovery in children
.
Clin J Sport Med
.
2018
;
28
(
2
):
139
145
.
52.
Messa
I,
Korcsog
K,
Abeare
C.
An updated review of the prevalence of invalid performance on the Immediate Post-Concussion and Cognitive Testing (ImPACT)
.
Clin Neuropsychol
.
2020
;
36
(
7
):
1613
1636
.
53.
Haider
MN,
Leddy
JJ,
Du
W,
Macfarlane
AJ,
Viera
KB,
Willer
BS.
Practical management: brief physical examination for sport-related concussion in the outpatient setting
.
Clin J Sport Med
.
2020
;
30
(
5
):
513
517
.
54.
Silverberg
ND,
Iaccarino
MA,
Panenka
WJ,
et al;
American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group Mild TBI Task Force
.
Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines
.
Arch Phys Med Rehabil
.
2020
;
101
(
2
):
382
393
.
55.
Patricios
JS,
Davis
GA,
Ahmed
OH,
et al
Introducing the Sport Concussion Office Assessment Tool 6 (SCOAT6)
.
Br J Sports Med
.
2023
;
57
(
11
):
648
650
.
56.
Neal
TL,
Diamond
AB,
Goldman
S,
et al
Inter-association recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the collegiate level: an executive summary of a consensus statement
.
J Athl Train
.
2013
;
48
(
5
):
716
720
.
57.
Broglio
SP,
Harezlak
J,
Katz
B,
Zhao
S,
McAllister
T,
McCrea
M;
CARE Consortium Investigators
.
Acute sport concussion assessment optimization: a prospective assessment from the CARE Consortium
.
Sports Med
.
2019
;
49
(
12
):
1977
1987
.
58.
Echemendia
RJ,
Bruce
JM,
Bailey
CM,
Sanders
JF,
Arnett
P,
Vargas
G.
The utility of post-concussion neuropsychological data in identifying cognitive change following sports-related MTBI in the absence of baseline data
.
Clin Neuropsychol
.
2012
;
26
(
7
):
1077
1091
.
59.
Ferris
LM,
Kontos
AP,
Eagle
SR,
et al
Utility of VOMS, SCAT3, and ImPACT baseline evaluations for acute concussion identification in collegiate athletes: findings from the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium
.
Am J Sports Med
.
2022
;
50
(
4
):
1106
1119
.
60.
Master
CL,
Scheiman
M,
Gallaway
M,
et al
Vision diagnoses are common after concussion in adolescents
.
Clin Pediatr (Phila)
.
2016
;
55
(
3
):
260
267
.
61.
Mucha
A,
Collins
MW,
Elbin
RJ,
et al
A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings
.
Am J Sports Med
.
2014
;
42
(
10
):
2479
2486
.
62.
Czerniak
LL,
Liebel
SW,
Garcia
GP,
et al;
CARE Consortium Investigators
.
Sensitivity and specificity of computer-based neurocognitive tests in sport-related concussion: findings from the NCAA-DoD CARE Consortium
.
Sports Med
.
2021
;
51
(
2
):
351
365
.
63.
Leddy
J,
Lesh
K,
Haider
MN,
et al
Derivation of a focused, brief concussion physical examination for adolescents with sport-related concussion
.
Clin J Sport Med
.
2021
;
31
(
1
):
7
14
.
64.
Kennedy
E,
Quinn
D,
Tumilty
S,
Chapple
CM.
Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: a retrospective analysis
.
Musculoskelet Sci Pract
.
2017
;
29
:
91
98
.
65.
Marshall
CM,
Vernon
H,
Leddy
JJ,
Baldwin
BA.
The role of the cervical spine in post-concussion syndrome
.
Phys Sportsmed
.
2015
;
43
(
3
):
274
284
.
66.
Schneider
KJ,
Meeuwisse
WH,
Palacios-Derflingher
L,
Emery
CA.
Changes in measures of cervical spine function, vestibulo-ocular reflex, dynamic balance, and divided attention following sport-related concussion in elite youth ice hockey players
.
J Orthop Sports Phys Ther
.
2018
;
48
(
12
):
974
981
.
67.
Streifer
M,
Brown
AM,
Porfido
T,
Anderson
EZ,
Buckman
JF,
Esopenko
C.
The potential role of the cervical spine in sports-related concussion: clinical perspectives and considerations for risk reduction
.
J Orthop Sports Phys Ther
.
2019
;
49
(
3
):
202
208
.
68.
Tiwari
D,
Goldberg
A,
Yorke
A,
Marchetti
GF,
Alsalaheen
B.
Characterization of cervical spine impairments in children and adolescents post-concussion
.
Int J Sports Phys Ther
.
2019
;
14
(
2
):
282
295
.
69.
Cheever
K,
Kawata
K,
Tierney
R,
Galgon
A.
Cervical injury assessments for concussion evaluation: a review
.
J Athl Train
.
2016
;
51
(
12
):
1037
1044
.
70.
Echemendia
RJ,
Meeuwisse
W,
McCrory
P,
et al
The Concussion Recognition Tool 5th Edition (CRT5): background and rationale
.
Br J Sports Med
.
2017
;
51
(
11
):
870
871
.
71.
McCrea
M.
Standardized mental status assessment of sports concussion
.
Clin J Sport Med
.
2001
;
11
(
3
):
176
181
.
72.
McCrea
M,
Kelly
JP,
Kluge
J,
Ackley
B,
Randolph
C.
Standardized assessment of concussion in football players
.
Neurology
.
1997
;
48
(
3
):
586
588
.
73.
McCrea
M,
Kelly
JP,
Randolph
C,
et al
Standardized Assessment of Concussion (SAC): on-site mental status evaluation of the athlete
.
J Head Trauma Rehabil
.
1998
;
13
(
2
):
27
35
.
74.
Iverson
GL,
Gardner
AJ,
Terry
DP,
et al
Predictors of clinical recovery from concussion: a systematic review
.
Br J Sports Med
.
2017
;
51
(
12
):
941
948
.
75.
Manley
G,
Gardner
AJ,
Schneider
KJ,
et al
A systematic review of potential long-term effects of sport-related concussion
.
Br J Sports Med
.
2017
;
51
(
12
):
969
977
.
76.
Buttner
F,
Terry
DP,
Iverson
GL.
Using a likelihood heuristic to summarize conflicting literature on predictors of clinical outcome following sport-related concussion
.
Clin J Sport Med
.
2021
;
31
(
6
):
e476
e483
.
77.
Collins
MW,
Kontos
AP,
Okonkwo
DO,
et al
Statements of agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting held in Pittsburgh, October 15–16, 2015
.
Neurosurgery
.
2016
;
79
(
6
):
912
929
.
78.
Kontos
AP,
Elbin
RJ,
Trbovich
A,
et al
Concussion Clinical Profiles Screening (CP Screen) tool: preliminary evidence to inform a multidisciplinary approach
.
Neurosurgery
.
2020
;
87
(
2
):
348
356
.
79.
Zemek
R,
Barrowman
N,
Freedman
SB,
et al;
Pediatric Emergency Research Canada (PERC) Concussion Team
.
Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED
.
JAMA
.
2016
;
315
(
10
):
1014
1025
.
80.
Zemek
RL,
Farion
KJ,
Sampson
M,
McGahern
C.
Prognosticators of persistent symptoms following pediatric concussion: a systematic review
.
JAMA Pediatr
.
2013
;
167
(
3
):
259
265
.
81.
Meehan
WP
III,
Mannix
R,
Monuteaux
MC,
Stein
CJ,
Bachur
RG.
Early symptom burden predicts recovery after sport-related concussion
.
Neurology
.
2014
;
83
(
24
):
2204
2210
.
82.
Meehan
WP
III,
O’Brien
MJ,
Geminiani
E,
Mannix
R.
Initial symptom burden predicts duration of symptoms after concussion
.
J Sci Med Sport
.
2016
;
19
(
9
):
722
725
.
83.
Van Pelt
KL,
Allred
CD,
Brodeur
R,
et al
Concussion-recovery trajectories among tactical athletes: results from the CARE Consortium
.
J Athl Train
.
2020
;
55
(
7
):
658
665
.
84.
Kontos
AP,
Jorgensen-Wagers
K,
Trbovich
AM,
et al
Association of time since injury to the first clinic visit with recovery following concussion
.
JAMA Neurol
.
2020
;
77
(
4
):
435
440
.
85.
Barnhart
M,
Bay
RC,
Valovich McLeod
TC.
The influence of timing of reporting and clinic presentation on concussion recovery outcomes: a systematic review and meta-analysis
.
Sports Med
.
2021
;
51
(
7
):
1491
1508
.
86.
Asken
BM,
McCrea
MA,
Clugston
JR,
Snyder
AR,
Houck
ZM,
Bauer
RM.
“Playing through it”: delayed reporting and removal from athletic activity after concussion predicts prolonged recovery
.
J Athl Train
.
2016
;
51
(
4
):
329
335
.
87.
Asken
BM,
Bauer
RM,
Guskiewicz
KM,
et al;
CARE Consortium Investigators
.
Immediate removal from activity after sport-related concussion is associated with shorter clinical recovery and less severe symptoms in collegiate student-athletes
.
Am J Sports Med
.
2018
;
46
(
6
):
1465
1474
.
88.
Cook
NE,
Iverson
GL,
Maxwell
B,
Zafonte
R,
Berkner
PD.
Adolescents with ADHD do not take longer to recover from concussion
.
Front Pediatr
.
2021
;
8
:
606879
.
89.
Cook
NE,
Iaccarino
MA,
Karr
JE,
Iverson
GL.
Attention-deficit/hyperactivity disorder and outcome after concussion: a systematic review
.
J Dev Behav Pediatr
.
2020
;
41
(
7
):
571
582
.
90.
Daniel
H,
Bornstein
SS,
Kane
GC,
et al
Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper
.
Ann Intern Med
.
2018
;
168
(
8
):
577
578
.
91.
Walker
RJ,
Smalls
BL,
Campbell
JA,
Strom Williams
JL,
Egede
LE.
Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review
.
Endocrine
.
2014
;
47
(
1
):
29
48
.
92.
Valovich McLeod
TC,
Fraser
MA,
Johnson
RJ.
Mental health outcomes following sport-related concussion
.
Athl Train Sports Health Care
.
2017
;
9
(
6
):
271
282
.
93.
Mrazik
M,
Brooks
BL,
Jubinville
A,
Meeuwisse
WH,
Emery
CA.
Psychosocial outcomes of sport concussions in youth hockey players
.
Arch Clin Neuropsychol
.
2016
;
31
(
4
):
297
304
.
94.
Kuehl
MD,
Snyder
AR,
Erickson
SE,
McLeod
TC.
Impact of prior concussions on health-related quality of life in collegiate athletes
.
Clin J Sport Med
.
2010
;
20
(
2
):
86
91
.
95.
Valovich McLeod
TC,
Bay
RC,
Snyder
AR.
Self-reported history of concussion affects health-related quality of life in adolescent athletes
.
Athl Train Sports Health Care
.
2010
;
2
(
5
):
219
226
.
96.
Chrisman
SP,
Richardson
LP.
Prevalence of diagnosed depression in adolescents with history of concussion
.
J Adolesc Health
.
2014
;
54
(
5
):
582
586
.
97.
Iverson
GL,
Williams
MW,
Gardner
AJ,
Terry
DP.
Systematic review of preinjury mental health problems as a vulnerability factor for worse outcome after sport-related concussion
.
Orthop J Sports Med
.
2020
;
8
(
10
):
2325967120950682
.
98.
Valovich McLeod
TC,
Register-Mihalik
JK.
Clinical outcomes assessment for the management of sport-related concussion
.
J Sport Rehabil
.
2011
;
20
(
1
):
46
60
.
99.
O’Neill
JA,
Cox
MK,
Clay
OJ,
et al
A review of the literature on pediatric concussions and return-to-learn (RTL): implications for RTL policy, research, and practice
.
Rehabil Psychol
.
2017
;
62
(
3
):
300
323
.
100.
Bacon
CEW,
Kay
MC,
McLeod
TCV.
Athletic trainers’ roles and responsibilities regarding academic adjustments as part of the concussion-management process in the secondary school setting
.
J Athl Train
.
2017
;
52
(
10
):
937
945
.
101.
Mental health best practices
.
National Collegiate Athletic Association Sports Science Institute
. Accessed December 5, 2023. https://www.ncaa.org/sports/2016/5/2/mental-health-best-practices.aspx
102.
Chang
CJ,
Putukian
M,
Aerni
G,
et al
American Medical Society for Sports Medicine position statement: mental health issues and psychological factors in athletes: detection, management, effect on performance, and prevention-executive summary
.
Clin J Sport Med
.
2020
;
30
(
2
):
91
95
.
103.
Putukian
M.
The psychological response to injury in student athletes: a narrative review with a focus on mental health
.
Br J Sports Med
.
2016
;
50
(
3
):
145
148
.
104.
Bernhardt
DT,
Roberts
WO
, eds.
PPE: Preparticipation Physical Evaluation
. 5th ed.
American Academy of Pediatrics
;
2019
.
105.
Lam
KC,
Marshall
AN,
Snyder Valier
AR.
Patient-reported outcome measures in sports medicine: a concise resource for clinicians and researchers
.
J Athl Train
.
2020
;
55
(
4
):
390
408
. .
106.
Champigny
CM,
Rawana
J,
Iverson
GL,
Maxwell
B,
Berkner
PD,
Wojtowicz
M.
Influence of anxiety on baseline cognitive testing and symptom reporting in adolescent student athletes
.
J Neurotrauma
.
2020
;
37
(
24
):
2632
2638
.
107.
Weber
ML,
Dean
JL,
Hoffman
NL,
et al
Influences of mental illness, current psychological state, and concussion history on baseline concussion assessment performance
.
Am J Sports Med
.
2018
;
46
(
7
):
1742
1751
.
108.
Wallace
J,
Learman
K,
Moran
R,
et al
Premorbid anxiety and depression and baseline neurocognitive, ocular-motor and vestibular performance: a retrospective cohort study
.
J Neurol Sci
.
2020
;
418
:
117110
.
109.
Covassin
T,
Elbin
RJ
III,
Larson
E,
Kontos
AP.
Sex and age differences in depression and baseline sport-related concussion neurocognitive performance and symptoms
.
Clin J Sport Med
.
2012
;
22
(
2
):
98
104
.
110.
Sarmiento
K,
Miller
GF,
Jones
SE.
Sports- or physical activity-related concussions and feelings of sadness or hopelessness among U.S. high school students: results from the 2017 Youth Behavior Risk Survey
.
J Sch Nurs
.
2022
;
38
(
2
):
203
209
.
111.
Sandel
N,
Reynolds
E,
Cohen
PE,
Gillie
BL,
Kontos
AP.
Anxiety and mood clinical profile following sport-related concussion: from risk factors to treatment
.
Sport Exerc Perform Psychol
.
2017
;
6
(
3
):
304
323
.
112.
Hutchison
M,
Mainwaring
LM,
Comper
P,
Richards
DW,
Bisschop
SM.
Differential emotional responses of varsity athletes to concussion and musculoskeletal injuries
.
Clin J Sport Med
.
2009
;
19
(
1
):
13
19
.
113.
Mainwaring
LM,
Hutchison
M,
Bisschop
SM,
Comper
P,
Richards
DW.
Emotional response to sport concussion compared to ACL injury
.
Brain Inj
.
2010
;
24
(
4
):
589
597
.
114.
McGuine
TA,
Pfaller
A,
Kliethermes
S,
et al
The effect of sport-related concussion injuries on concussion symptoms and health-related quality of life in male and female adolescent athletes: a prospective study
.
Am J Sports Med
.
2019
;
47
(
14
):
3514
3520
.
115.
Broglio
SP,
Kontos
AP,
Levin
H,
et al
National Institute of Neurological Disorders and Stroke and Department of Defense Sport-Related Concussion Common Data Elements Version 1.0 recommendations
.
J Neurotrauma
.
2018
;
35
(
23
):
2776
2783
.
116.
Rice
SM,
Parker
AG,
Rosenbaum
S,
Bailey
A,
Mawren
D,
Purcell
R.
Sport-related concussion and mental health outcomes in elite athletes: a systematic review
.
Sports Med
.
2018
;
48
(
2
):
447
465
.
117.
Asken
BM,
Sullan
MJ,
Snyder
AR,
et al
Factors influencing clinical correlates of chronic traumatic encephalopathy (CTE): a review
.
Neuropsychol Rev
.
2016
;
26
(
4
):
340
363
.
118.
Hutchison
MG,
Di Battista
AP,
McCoskey
J,
Watling
SE.
Systematic review of mental health measures associated with concussive and subconcussive head trauma in former athletes
.
Int J Psychophysiol
.
2018
;
132
(
pt A
):
55
61
.
119.
McAvoy
K,
Eagan-Johnson
B,
Halstead
M.
Return to learn: transitioning to school and through ascending levels of academic support for students following a concussion
.
NeuroRehabilitation
.
2018
;
42
(
3
):
325
330
.
120.
Gioia
GA,
Glang
AE,
Hooper
SR,
Brown
BE.
Building statewide infrastructure for the academic support of students with mild traumatic brain injury
.
J Head Trauma Rehabil
.
2016
;
31
(
6
):
397
406
.
121.
Putukian
M,
Purcell
L,
Schneider
KJ,
et al
Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis
.
Br J Sports Med
.
2023
;
57
(
12
):
798
809
.
122.
Gioia
GA.
Medical-school partnership in guiding return to school following mild traumatic brain injury in youth
.
J Child Neurol
.
2016
;
31
(
1
):
93
108
.
123.
Wan
AN,
Nasr
AS.
Return to learn: an ethnographic study of adolescent young adults returning to school post-concussion
.
J Clin Nurs
.
2021
;
30
(
5–6
):
793
802
.
124.
DeMatteo
C,
Stazyk
K,
Giglia
L,
et al
A balanced protocol for return to school for children and youth following concussive injury
.
Clin Pediatr (Phila)
.
2015
;
54
(
8
):
783
792
.
125.
Ransom
DM,
Vaughan
CG,
Pratson
L,
Sady
MD,
McGill
CA,
Gioia
GA.
Academic effects of concussion in children and adolescents
.
Pediatrics
.
2015
;
135
(
6
):
1043
1050
.
126.
Iverson
GL,
Gioia
GA.
Returning to school following sport-related concussion
.
Phys Med Rehabil Clin N Am
.
2016
;
27
(
2
):
429
436
.
127.
DeMatteo
C,
Bednar
ED,
Randall
S,
Falla
K.
Effectiveness of return to activity and return to school protocols for children postconcussion: a systematic review
.
BMJ Open Sport Exerc Med
.
2020
;
6
(
1
):
e000667
.
128.
McLeod
TC,
Lewis
JH,
Whelihan
K,
Bacon
CE.
Rest and return to activity: a systematic review of the literature
.
J Athl Train
.
2017
;
52
(
3
):
262
287
.
129.
Williams
RM,
Welch
CE,
Parsons
JT,
McLeod
TC.
Athletic trainers’ familiarity with and perceptions of academic accommodations in secondary school athletes after sport-related concussion
.
J Athl Train
.
2015
;
50
(
3
):
262
269
.
130.
Weber
ML,
Welch
CE,
Parsons
JT,
Valovich McLeod
TC.
School nurses’ familiarity and perceptions of academic accommodations for student-athletes following sport-related concussion
.
J Sch Nurs
.
2015
;
31
(
2
):
146
154
.
131.
Runyon
LM,
Welch Bacon
CE,
Neil
ER,
Eberman
LE.
Understanding the athletic trainer's role in the return-to-learn process at National Collegiate Athletic Association Division II and III institutions
.
J Athl Train
.
2020
;
55
(
4
):
365
375
.
132.
Kasamatsu
T,
Cleary
M,
Bennett
J,
Howard
K,
McLeod
TV.
Examining academic support after concussion for the adolescent student-athlete: perspectives of the athletic trainer
.
J Athl Train
.
2016
;
51
(
2
):
153
161
.
133.
Weber
ML,
Welch Bacon
CE,
McLeod
TV.
School nurses’ management and collaborative practices for student-athletes following sport-related concussion
.
J Sch Nurs
.
2019
;
35
(
5
):
378
387
.
134.
Kay
MC,
Valovich McLeod
TC,
Erickson
CD,
Wagner
AJ,
Welch Bacon
CE.
Athletic trainers’ perceptions of academic adjustment procedures for student-athletes with concussion
.
Athl Train Sports Health Care
.
2018
;
10
(
5
):
198
206
.
135.
Leddy
JJ,
Haider
MN,
Hinds
AL,
Darling
S,
Willer
BS.
A preliminary study of the effect of early aerobic exercise treatment for sport-related concussion in males
.
Clin J Sport Med
.
2019
;
29
(
5
):
353
360
.
136.
Howell
DR,
Hunt
DL,
Aaron
SE,
Meehan
WP
III,
Tan
CO.
Influence of aerobic exercise volume on postconcussion symptoms
.
Am J Sports Med
.
2021
;
49
(
7
):
1912
1920
.
137.
Leddy
JJ,
Burma
JS,
Toomey
CM,
et al
Rest and exercise early after sport-related concussion: a systematic review and meta-analysis
.
Br J Sports Med
.
2023
;
57
(
12
):
762
770
.
138.
Schneider
KJ,
Leddy
JJ,
Guskiewicz
KM,
et al
Rest and treatment/rehabilitation following sport-related concussion: a systematic review
.
Br J Sports Med
.
2017
;
51
(
12
):
930
934
.
139.
Schneider
KJ,
Critchley
ML,
Anderson
V,
et al
Targeted interventions and their effect on recovery in children, adolescents and adults who have sustained a sport-related concussion: a systematic review
.
Br J Sports Med
.
2023
;
57
(
12
):
771
779
.
140.
Campbell
RA,
Gorman
SA,
Thoma
RJ,
et al
Risk of concussion during sports versus physical education among New Mexico middle and high school students
.
Am J Public Health
.
2018
;
108
(
1
):
93
95
.
141.
Leddy
JJ,
Hinds
AL,
Miecznikowski
J,
et al
Safety and prognostic utility of provocative exercise testing in acutely concussed adolescents: a randomized trial
.
Clin J Sport Med
.
2018
;
28
(
1
):
13
20
.
142.
Majerske
CW,
Mihalik
JP,
Ren
D,
et al
Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance
.
J Athl Train
.
2008
;
43
(
3
):
265
274
.
143.
Soberg
HL,
Andelic
N,
Langhammer
B,
Tamber
AL,
Bruusgaard
KA,
Kleffelgaard
I.
Effect of vestibular rehabilitation on change in health-related quality of life in patients with dizziness and balance problems after traumatic brain injury: a randomized controlled trial
.
J Rehabil Med
.
2021
;
53
(
4
):
jrm00181
.
144.
Ahluwalia
R,
Miller
S,
Dawoud
FM,
et al
A pilot study evaluating the timing of vestibular therapy after sport-related concussion: is earlier better
?
Sports Health
.
2021
;
13
(
6
):
573
579
.
145.
Schneider
KJ,
Meeuwisse
WH,
Nettel-Aguirre
A,
et al
Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial
.
Br J Sports Med
.
2014
;
48
(
17
):
1294
1298
.
146.
Schneider
KJ,
Meeuwisse
WH,
Barlow
KM,
Emery
CA.
Cervicovestibular rehabilitation following sport-related concussion
.
Br J Sports Med
.
2018
;
52
(
2
):
100
101
.
147.
Kontos
AP,
Eagle
SR,
Mucha
A,
et al
A randomized controlled trial of precision vestibular rehabilitation in adolescents following concussion: preliminary findings
.
J Pediatr
.
2021
;
239
:
193
199
.