For the athletic trainer (AT), the most critical aspect of concussion care is to know when it is safe to allow a player to continue to play.
In the United States each year, approximately 1.6-3.8 million athletes are affected by sports and recreation-related concussions (Brain Injury Research Institute, 2023). For the athletic trainer (AT), the most critical aspect of concussion care is to know when it is safe to allow a player to continue to play or remove them from play. Following the decision to allow an athlete to play or not, knowing how to safely return them to sport is paramount.
What to do after a suspected head injury
In the initial moments after a suspected head injury, the following steps should be taken immediately:
- Observe the athlete to determine if (s)he has sustained a loss of consciousness or exhibits any immediate confusion, memory problems, and/or balance issues. The AT, if (s)he knows the athlete should observe the athlete’s behavior for noticeable changes in mood and/or personality. Athletes may self-report headaches, subjective feelings of “not feeling right,” neck pain and/or head pressure, and more alarming symptoms may present as gait ataxia and vacant stare (Daly, 2022).
- When a concussion is suspected, a comprehensive medical evaluation should be completed as soon as possible by a healthcare professional with knowledge of concussion management strategies and access to tools like the King–Devick (KD) oculomotor test (Daly, 2022). A medical evaluation may include a physical examination, a review of the athlete’s medical history, and a discussion of their current symptoms.
How to assess and diagnose a concussion
Several assessment tools can help diagnose a concussion, both on-field during play and before and after play. The Sports Concussion Assessment Tool is one of the most common concussion care diagnostic tools and involves a series of tests that include:
- Symptom evaluation such as athlete self-reported headaches, dizziness, or sensitivity to light and/or noise.
- Cognitive assessment which includes an evaluation of the athlete’s memory, concentration, and reaction time.
- Balance assessment that examines both the athlete’s balance and general motor coordination.
- Coordination assessment which takes into consideration the athlete’s coordination and general motor skills.
- Clinical evaluation. Following a suspected concussion, the athlete should be examined in-office by a healthcare professional who will conduct a thorough physical exam to determine the athlete’s overall health and neurological function.
Removal from play
As a rule, the AT should err on the side of caution. Although athletes may not be happy to be removed from play, the AT’s primary role is to protect the health and well-being of the athlete. Where a concussion is suspected an athlete should be pulled from play and cleared to return to sport only by a licensed medical professional with knowledge of concussion care and management.
The decision to pull an athlete from play is immediate and determined by a different set of guidelines than those that govern when it is safe to return to sport following a positive concussion diagnosis.
As a rule, the athlete should rest until their symptoms have completely resolved. Once symptoms have resolved s(he) can resume normal activities of daily living, excluding sports play (Picket, 2021).
When the athlete can resume normal activity without the reappearance of concussion-related symptoms and has been cleared to return to play, follow the step-by-step return to sport protocol:
- Step 1: Light aerobic exercise: The athlete can begin a light aerobic exercise, such as walking or recumbent or upright stationary cycling. The goal is to increase the heart rate and begin to retrain cardiovascular endurance.
- Step 2: Sport-specific exercise: The athlete can begin a sport-specific exercise, such as sprint drills, throwing a ball, or skating. The goal is to resume sport-specific skill training without any impact or contact and to further reestablish cardiovascular endurance for sport.
- Step 3: No-contact sport-specific training: The athlete can participate in no-contact training drills, such as passing a ball. The goal is to initiate critical thinking and reintroduce skills that require greater motor coordination. At this stage, resistance training may be reinitiated; however, training loads should be minimized initially and reintroduced progressively.
- Step 4: Full-contact training: The athlete can participate in full-contact training drills, such as scrimmages or practices if s(he) is psychologically ready. Athletes will respond differently to the psychological rigors of head trauma and recovery and although a medical assessment may deem them ready to return to sport, the AT should verify willingness and readiness.
- Step 5: Return to sport: The athlete can return to full participation in their sport.
Concussion care and recovery
Concussions in athletics are a serious concern. Athletes can take weeks to months to recover. Concussions may also cause long-term struggles that include cognitive impairment, chronic traumatic encephalopathy (CTE), mental illness, depression, or suicide (Pickett, 2021).
The AT plays a role in both determining when to pull an athlete from competition after a suspected head injury and how to return them safely and effectively to sports. Researchers have much still to learn about concussion care and athletics. For now, the best practices are to approach head injury with caution and partner with medical professionals for the best outcomes.
This article was written by Amy Ashmore, PhD.