This course will be updated or discontinued on or before Saturday, November 13, 2027
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Outcomes
>92% of participants will know how to recognize and direct care for sports-related concussions in the setting of student-athletes.
Objectives
At the conclusion of this course, the participant will be able to:
Demonstrate the need for concussion education.
Explore prevention strategies to reduce the rate of concussions.
Calculate when to implement at least two separate assessment tools.
Recommend at least two evidence-based management strategies for concussions.
Investigate the long-term effects of concussion.
CEUFast Inc. and the course planning team for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Nursing Assistants from California, only. You must read the material on this page before you can take the test. The California Department of Public Health, Training Program Review Unit has determined that is the only way to prove that you actually spent the time to read the course. Less
Concussion is reported to be a public health crisis (Jackson & Starling, 2019). A public health crisis is defined as an event or situation that poses a significant threat to the health and well-being of a specific population. There are an estimated 1.1 million to 1.9 million sport-related concussions that occur yearly in 18-year-olds and younger in the USA (Broglio et al., 2024). Almost 50% of all concussions result from sports or recreational activity participation (Hallock et al., 2023; Mucha, 2024). Concussion also continues to be a significant concern among the generally physically active population as well, with half a million emergency department visits annually in the United States (Broglio et al., 2024). Athletes can have long-lasting effects following a concussion, and concussions have been found to impact the whole human body (Patel et al., 2024). Concussions can take athletes out of the game, out of the classroom, and even out of normal daily activities. A significant amount of time and funding has been devoted to concussion research over the last decade and a half. With this new knowledge, management recommendations have been created to improve concussion outcomes, effectively resolve concussion symptoms, and enable athletes to return to activity more safely, sometimes within a quicker timeframe.
Healthcare providers, such as athletic trainers (ATs), physical therapists (PTs), and nurse practitioners (NPs), are often the first to detect and diagnose many sport-related injuries, including concussions. Many times, it is an AT that is first to interact with student-athletes when it comes to injuries, and may be the first to provide care to the student-athlete who has experienced a sports-related concussion. As concussion science continues to evolve, it is the responsibility of healthcare providers to stay relevant for themselves and their athletic population. With concussions having such an impact on the body, healthcare providers are urged to address this public health crisis.
The 6th International Conference on Concussion in Sport was held in Amsterdam in October 2022, resulting in a consensus statement that was published in 2023. The “Amsterdam 2022 International Consensus Statement on Concussion in Sport” summarises published evidence at the time of the conference. “Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings, and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components” (Patricios et al., 2023a).
The National Athletic Trainer Association (NATA) Bridge Statement was published in 2024. This was the first time NATA had updated its concussion position statement in ten years, and it was created to align with the recommendations of the International Consensus Statement described above. The NATA recommendations aim to “update the state of the evidence on the management of patients with sport-related concussions, specifically in the areas of education, assessment advances, prognostic recovery indicators, mental health considerations, academic considerations, and exercise, activity, and rehabilitation management strategies” (Broglio et al., 2024).
This course will discuss the education, prevention, evaluation, management, and treatment of concussion in the setting of student-athletes. Although a sports-related concussion is a specific mechanism subset of all concussions, for the purposes of this course and ease of reading, a sports-related concussion will be referred to as a concussion.
A concussion is defined as a temporary disturbance of brain function and is a form of traumatic brain injury (TBI) (Hallock et al., 2023). While TBI can be mild, moderate, or severe, 90% of all TBIs are mild. Mild traumatic brain injuries (mTBIs) are classified as: no intracranial abnormalities are seen on CT or MRI Scan; a loss of consciousness for less than 30 minutes; and/or less than 24 hours period of posttraumatic amnesia. The American Congress of Rehabilitation indicates that the terms concussion and mild traumatic brain injury can be “used interchangeably when results of neuroimaging are normal or when neuroimaging is not clinically indicated” (Leddy, 2025); although there is debate on whether concussion and mild TBI are distinctive (Hallock et al., 2023). Sports-related concussions occur specifically due to biomechanical forces induced on the body or head, resulting in acceleration, deceleration, or rotational forces on the brain (Hallock et al., 2023). This can result from a direct hit to the head in sports, such as when the head hits the ground, being tackled in sports like football, hockey, or lacrosse, or being struck in the head by a piece of equipment (such as a baseball bat) or an opponent. A concussion can also occur from a hit to the body, leading to excessive force to the brain. The important concept of this is that you don’t have to be hit in the head to sustain a concussion. A concussion typically results in vague/diffuse injuries, making it challenging to recognize and diagnose, and generally includes axonal injury, but also vascular injury and brain edema (Hallock et al., 2023).
It was once believed that a concussion resulted from a “coup-contrecoup” mechanism, or the brain bouncing off the skull from the impact, and then rebound impact, resulting in bruising and cell injury. Current evidence, however, supports that a concussion occurs as a result of rapid acceleration, deceleration, or rotational forces that cause a shearing effect of the axons in the brain (Hallock et al., 2023). Secondarily, this diffuse axonal injury leads to metabolic disturbances in the brain, known as “the hypermetabolic or neurometabolic cascade of concussion” (Hallock et al., 2023). Additionally, the shearing forces of concussion can damage endothelial cells in small vessels, which causes a reduced cerebral blood flow. These injuries, together, lead to a mismatch between the glucose supply (decreased due to reduced blood flow) and demand (increased due to the need for healing), resulting in acute disruption of neuronal function (Hallock et al., 2023).
Unfortunately, symptoms of a concussion are not always obvious. Unlike other orthopedic injuries, the symptoms of a concussion cannot always be seen by observers, such as a parent, coach, or healthcare provider. Some of the symptoms may be physical, such as balance problems, while others are cognitive, including memory disturbances. Adding to the challenge, symptoms vary significantly among individuals, and they may occur immediately following the injury or be delayed in onset. Sometimes, it is just a feeling of being a “little off.” Concussions in children can be especially hard to recognize because they may not be able to describe how they feel (Mayo Clinic, n.d.).
Common Symptoms of Concussion (Mayo Clinic, n.d.):
Headache
Ringing in the ears
Nausea
Vomiting
Fatigue or drowsiness
Blurry vision
Confusion or feeling “in a fog”
Dizziness or “seeing stars”
Difficulty remembering the time around the event
Loss of consciousness
Slurred speech
Delayed response to questions
Dazed appearance
Forgetfulness, asking the same question over and over.
Difficulty concentrating
Irritability, feeling emotional, or other personality changes
Sensitivity to light or noise
Trouble falling asleep or sleeping too much
Changes in taste or smell
A person may experience one or several of these symptoms. It is also important to realize that a person does not have to have been “knocked out” or lose consciousness to have sustained a concussion. It is the responsibility of all stakeholders (athletes, coaches, administrators, parents, and healthcare providers) to remove athletes who are suspected of having a concussion so that they can be properly assessed. Any external force to the head or body that can be suspected to alter brain function should be assessed, even if the athlete does not report it. If athletes are delayed from removing themselves from sport, they can experience more severe symptoms and take longer to achieve recovery. The National Football League has been using independent ATs in the broadcast booth as an additional layer of safety in detecting concussions among professional athletes since 2011(Mack et al., 2019).
If an athlete, coach, parent, or medical professional suspects that an athlete has sustained a concussion, there must be an IMMEDIATE DISCONTINUATION of participation! Athletes should be advised not to hide any symptoms and strongly encouraged to report any signs or symptoms of concussion that they may be experiencing to their athletic trainer, coach, parent, or teacher. There should be no “let's wait and see if things get better or worse.” Any injury to the head or body that causes suspicion of alteration to the brain should be assessed for concussion.When in doubt, sit them out! If a concussion is confirmed by a healthcare provider, athletes should not return to play on the same day.
The risks of continuing to participate with a concussion can be severe or life-threatening and could involve:
Second Impact Syndrome, a rare, but potentially fatal condition in which a person experiences a second head injury before completely recovering from a prior head injury (May et al., 2023).
It is important for concussions to be recognized and evaluated by healthcare providers trained in assessing sport-related concussions. The quicker an athlete is assessed, the better the injury can be managed, and the quicker they can return to play. Ideally, evaluation and management can begin on the sideline immediately after the injury, most often by an AT.
Detecting concussions begins with assessing the athlete. Healthcare providers should note that some concussions may be obvious without the need to assess all domains (Broglio et al., 2024). A thorough assessment for concussion focuses on symptoms, neurologic and neurocognitive status, and motor control, with new evidence suggesting the inclusion of vision and vestibulo-ocular function. There are many tools for assessing these domains. Each tool can be used at different times during the assessment.
It is helpful to categorize each stage of the assessment as an acute assessment or a post-acute assessment. For acute assessment, healthcare providers should prioritize protecting the athlete from second-impact syndrome and rule out any serious injuries. Acute assessment is performed within three days of injury. Healthcare providers should turn to the Sport Concussion Assessment Tool (SCAT) as part of the concussion assessment. The SCAT is a standardized tool for assessing concussion. Using the SCAT within the first 72 hours of injury has been shown to be ideal and more effective (Echemendia et al., 2023a). The SCAT is free and easy to administer. It is best used on the sideline or in the clinic and takes approximately 15 minutes. It is a tool that surveys symptoms and reports on their severity. The SCAT has evolved, with the most recent version being the SCAT6, which was unveiled in 2022 (Echemendia et al., 2023b). There is a child’s version specifically designed for children aged 12 and under. The SCAT includes the Post-Concussion Symptom Scale, Neurological Sign Report, Glasgow Coma Scale (GCS), Standardized Assessment of Concussion (SAC), and the Modified Balance Error Scoring System (M-BESS). Healthcare providers should understand the diagnostic accuracy of each component. The SCAT did not demonstrate an increased value over baseline testing in standard normative and clinical evaluations of cognitive measures and balance/postural stability (Echemendia et al., 2023a). The use of the SAC is a reliable and objective measure of cognition. It consists of orientation, immediate memory, concentration, and delayed recall. This is tested with either a 5-word or a 10-word list; however, the 5-word list has been met with criticism. Healthcare providers should incorporate a 10-word list. One study showed that when the SAC was used for baseline testing, athletes performed better (Harmon et. al., 2024). This indicates the need for cognitive assessment and other objective indicators. An injury such as a concussion is heterogeneous and requires a multimodal approach to assessment and management (McKee et al., 2024). Abbreviated self-report scales administered acutely may offer the ability to diagnose athletes with concussion and controls, and may be useful for screening purposes when time is limited (Echemendia et al., 2023a).
With a post-acute assessment, more than three days post-injury, the goal should be to assess specific concussion deficiencies and minimize their duration. Similar to the SCAT6, the SCOAT6 is a tool for evaluating concussion in a controlled office environment, typically 72 hours or longer following concussion (Patricios et al, 2023b).
Healthcare providers should start by taking a history and allowing the athlete to self-report their symptoms. A concussion is just one of the few diagnoses that rely strictly on patient-reported symptoms. Important information to gather is:
A description of the injury. How did the concussion occur/what was the mechanism of the current concussion?
The number of previous concussions
The date and mechanisms for each prior concussion
The duration of symptoms and recovery time for prior concussions
The age of the first concussion.
It is also important that healthcare providers rule out any confounding factors that can mimic or exacerbate symptoms. Factors such as preexisting psychiatric illnesses, emotional well-being, and life stressors were associated with an increase in symptoms (Trinh et al., 2020). It is essential to consider these external factors to ensure that student-athletes are evaluated accurately. The longer a concussion is not assessed and diagnosed, the longer the average recovery time can be (Barnhart et al., 2021). Understanding the whole athlete and the multifactorial influence is helpful for clinicians to identify and recognize potential difficulties in concussion recovery. Iverson et al. (2020) showed that preexisting mental health conditions were associated with a longer recovery from concussions. Conditions such as attention-deficit/hyperactivity disorder (ADHD), learning disability, depression, sleep disorders, previous migraines or family history, neurological disorders, or even stress and other orthopedic injuries have been shown to temporarily worsen symptoms. It is highly recommended that mental health status be included during the preparticipation exam and/or during the concussion assessment process. ATs and other non-mental health clinicians should know that they can screen but not diagnose mental health issues. There are six youth-related empirically validated patient-reported instruments that can be used for assessing “overall mental health”, and three adult-related instruments (Beidas et al., 2015; Becker-Haimes et al., 2020). These free, brief, and accessible measures can be used in part with other concussion assessment tools. Healthcare providers should have a policy in place to determine when and to whom they should refer individuals for mental health care. The management of a concussion is a multidisciplinary team approach. Having a qualified mental health professional is imperative when dealing with concussions. This will enable the improvement of clinical care, ultimately leading to better patient outcomes.
Symptom assessments should not be a stand-alone measure and should be combined with other tests (Mucha & Trbovich, 2019). Headaches, dizziness, and difficulty concentrating were the most commonly reported symptoms (Chandran et al., 2020). When assessing a suspected concussion, healthcare professionals should acknowledge that concussion symptoms can be delayed for up to several minutes after the incident, with one report suggesting up to 60 minutes (Olson et al., 2020). Athletes should be observed for delayed symptom onset and re-assessed as needed.
To determine the presence of impairments after a concussion, clinicians should initiate their assessment with one of the following tools: the Post-Concussion Symptom Scale (PCSS), Post-Concussion Symptom Inventory, Health and Behaviour Inventory, or Rivermead Post-Concussion Symptoms Questionnaire. The Post-Concussion Symptom Scale is the best measurement for distinguishing acute concussion in athletes and should be used throughout a typical period of recovery. There should be a balance in the frequency of reassessment of concussed athletes, as repetitive use may reinforce a hyperfixation on impairment. The Post-Concussion Symptom Scale is a self-reported score of physical, cognitive, sleep, and emotional symptoms. Each symptom is rated on a 0-6 scale, where 0 indicates no symptom and 6 indicates severe symptoms. The total score ranges from 0 to 132. Higher scores indicate a greater severity of symptoms.
Post-Concussion Symptom Scale
Symptom
None
Mild
Moderate
Severe
Headache
0
1
2
3
4
5
6
Nausea
0
1
2
3
4
5
6
Vomiting
0
1
2
3
4
5
6
Balance Problems
0
1
2
3
4
5
6
Dizziness
0
1
2
3
4
5
6
Visual Problems
0
1
2
3
4
5
6
Fatigue
0
1
2
3
4
5
6
Sensitivity to Light
0
1
2
3
4
5
6
Sensitivity to Noise
0
1
2
3
4
5
6
Numbness/Tingling
0
1
2
3
4
5
6
Feeling Foggy
0
1
2
3
4
5
6
Feeling Slowed Down
0
1
2
3
4
5
6
Difficulty Concentrating
0
1
2
3
4
5
6
Difficulty Remembering
0
1
2
3
4
5
6
Drowsiness
0
1
2
3
4
5
6
Sleeping Less than Usual
0
1
2
3
4
5
6
Sleeping More than Usual
0
1
2
3
4
5
6
Trouble Falling Asleep
0
1
2
3
4
5
6
Irritability
0
1
2
3
4
5
6
Sadness
0
1
2
3
4
5
6
Nervousness
0
1
2
3
4
5
6
Feeling More Emotional
0
1
2
3
4
5
6
Pain other than Headache
0
1
2
3
4
5
6
Total points of all symptoms __________ Exertion: Do these symptoms worsen with: Physical activity □ Yes □ No □ Not Applicable
Thinking/Cognitive Activity □ Yes □ No □ Not Applicable
Headache is the most common symptom following a concussion, with athletes expressing symptoms in over 90% of cases (Chandran et al., 2020). Some post-traumatic headaches have been shown to resolve within 3 months, and others within 24 months (Mavroudis et al., 2023). Post-traumatic headaches are associated with worse clinical presentation and often need preventative medication. Sometimes, post-traumatic headaches can turn into post-traumatic migraine. Post-traumatic migraine is often aggravated by normal physical activity (eg, walking or climbing stairs) and frequently occurs with nausea and/or vomiting or photophobia and phonophobia. It is important to differentiate between the two issues. Assessment tools are needed so that clinicians can help quantify pain and report how this pain is disabling. Assessment tools such as the International Headache Society, the Migraine Assessment Tool, Migraine Disability Assessment test, and the Headache Impact Test may be utilized.
A complete cervical spine evaluation should be included. Cervical assessment helps differentiate whether symptoms are due to a concussion or whiplash-associated disorder. This is where healthcare providers will have to utilize their skills and knowledge. Testing of strength, range of motion, and proprioception should be conducted to assess these parameters. If additional testing is needed, healthcare professionals may use tools such as the Cervical Torsion Test (CTT). This test requires an additional device referred to as a video nystagmography. Other assessment tools include the head relocation test, postural stability testing, and smooth pursuit neck torsion test, which also require the expertise of a healthcare provider.
Research from Gowrisankaran et al. (2021) found that 88% of athletes suffered ocular impairment following a concussion. This research shows the importance of healthcare providers' understanding of ocular-specific assessment tools. Healthcare providers may use the Vestibular/Ocular Motor Screening (VOMS), which is a more concussion-specific test (Mucha et al., 2014).
Vestibular/Ocular Motor Screening (VOMS) for Concussion (Mucha et al., 2014)
Vestibular/Ocular Motor Test:
Not Tested
Headache 0-10
Dizziness 0-10
Nausea 0-10
Fogginess 0-10
Comments
Baseline Symptoms:
Smooth Pursuits
Saccades- Horizontal Saccades- Vertical
Convergence (Near Point in cm)
Measure 1: ____ Measure 2: ____ Measure 3: ____
VOR- Horizontal
VOR-Vertical
Visual Motion Sensitivity
The King-Devick (KD) Test is another respected choice; however, it does require a baseline measurement. The primary benefit is that the King-Devick test takes approximately 2 minutes to complete; however, it is well established that King-Devick has high rates of false-positive findings, as well as inadequate sensitivity and specificity. Therefore, healthcare providers should exercise caution when relying solely on King-Devick testing. The VOMS is a lengthy test, but it tests more aspects of oculomotor and vestibular function. Due to the length of testing, healthcare professionals should be aware of when to modify their approach according to individual needs. Another general tool is the Convergence Insufficiency Symptom Survey. This tool is not specifically developed for concussion management and should be used in conjunction with other tools. Referrals to a vision specialist can also be utilized for a detailed examination if warranted. Most ocular assessments were not created with concussion in mind. Healthcare providers should include more tools to detect post-concussion measures.
Another high impairment is vestibular issues, with 60% of athletes having some issue with dizziness, nausea, and imbalance (Mucha & Trbovich, 2019). The Balance Error Scoring System (BESS) and the previously mentioned VOMS are tools used to assess this domain. When testing the BESS, it is suggested that the same healthcare provider should evaluate balance performance. Other general tools, such as the Dix-Hallpike test, supine roll test, dynamic visual acuity test, head impulse test, and head-shake nystagmus test, can also be performed. These tests are typically completed in a clinical setting and should be performed by a healthcare provider with experience in administering these measures. Vestibular impairment can cause numerous dysfunctions, so a multidimensional screening is necessary.
For autonomic assessment, clinicians should utilize the Buffalo Concussion Treadmill Test or the McMaster All-Out Progressive Continuous Cycling Test. Both tests assess exercise tolerance. Exercise tolerance is defined as the inability to exercise at or near one's age-appropriate maximum heart rate due to exacerbation of concussion-related symptoms (Haider et al., 2022). This dysfunction can be noticed when an athlete has been deconditioned from overresting and inactivity following a concussion. These tests can also assess symptom recurrence with increased physical exertion. These tools may be included during the Return-to-Play (RTP) process, which will be discussed later in the course. The goal is to identify symptoms that are not obvious at rest. For a more severe presentation, clinicians may use the head upright tilt table test, heart rate variability test, or the Valsalva maneuver.
Another domain that affects post-acute concussion symptoms is mood/psychiatric. There are no standardized tools used in the setting of concussions. A few self-report questionnaires that can be used include the Brief Symptom Inventory, Beck Anxiety Inventory, Beck Depression Inventory, Brief Symptom Inventory-18, and the Center for Epidemiologic Studies Depression Scale (Mucha & Trbovich, 2019). The Post-Concussion Symptoms Scale subscales can also be used for behaviour health screening or assessment. Including this in the assessment allows healthcare providers to understand the distress the athlete may be facing. Psychiatric disorders are both risk factors and outcomes of a brain injury. Mental health problems can be a difficult layer for many healthcare providers to experience as they try to help student-athletes return to their pre-injury mood. Many times, post-concussion symptoms are too low to warrant a psychiatric diagnosis (Howlett et al., 2022). It is essential that healthcare providers establish communication with a mental health provider who can facilitate a timely referral if needed.
Cognitive assessment tools can also be used for post-acute assessment. These tools are most effective when used in conjunction with a baseline test established prior to the concussion. Baseline testing can be useful in aiding the recovery process of a concussion; however, a baseline is not a required test to assess or diagnose a concussion. Some states, schools, and sports associations require baseline testing. A baseline test may be useful in facilitating concussion education, but shows little evidence of diagnostic effectiveness (Pandey et al., 2025). Cognitive assessments were among the first tools used for concussion assessment. They are useful when athletes are not forthcoming about their symptoms. The most common tools are the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), the Axon Sports Computerized Cognitive Assessment tool, HeadMinder Concussion Resolution Index, and SWAY Medical.
Each platform records:
Attention
Processing speed
Memory processing.
Each clinical tool has its strengths and weaknesses. These tests can also be costly and time-consuming, especially when considering baseline testing and time-of-injury assessments. It is the responsibility of the healthcare provider to know when and how to use each tool in the concussion process. Daly et al. (2022) report that a lack of resources and education can prevent the effective assessment of concussions.
There is no gold standard for determining which assessment tool to use when evaluating a concussion; however, several key elements should be included in the evaluation process. Assessment should incorporate aspects of neurological, vestibular, ocular motor, visual, neurocognitive, psychological, and cervical function. A concussion assessment can get confusing and challenging. However, healthcare providers should assess athletes suffering from a concussion in multiple domains, which aligns with best practice. Often, it can be challenging to determine when to administer assessment tools, how often to retest an athlete, and the limited number of freely available assessment tools. It is the duty of each healthcare provider to be knowledgeable about what is considered best practice in the literature and in their specific setting. It is recommended that concussion protocols, assessment strategies, policies, and procedures be reviewed at least annually to reflect the current literature.
Sometimes diagnostic imaging, such as CT scans and MRI, is ordered as part of a concussion examination. While these additional images can be helpful, neuroimaging is not necessary for the assessment of acute concussion. A concussion is classified as a functional defect rather than a structural defect. Images can be used if healthcare providers suspect structural damage. Plain radiography of the head has no role in the evaluation of concussion unless it is to rule out any paired head and neck injury. Cervical imaging may be indicated if the mechanism of injury for the concussion was consistent with one that could cause cervical injury as well.
Possible Neck Injury
Currently, there is insufficient evidence to support the use of body fluids or images for diagnostic or prognostic purposes in concussion (Herring et al., 2021). It is essential that all stakeholders are aware of when additional images may be required during the assessment stage. A few imaging algorithms were created to identify individuals who are needed for neuroimages following a posttraumatic head injury. The most widely used algorithms are:
The Canadian CT Head Rule
New Orleans Criteria
The Pediatric Emergency Care Applied Research Network (PECARN) (Scorza & Cole, 2019).
CTs are preferred over MRI but run the risk of high doses of radiation (Lumba-Brown et al., 2018). Most practice guidelines even discourage post-acute neuroimaging in patients who are not recovering (Silverberg et al., 2020). If athletes continue to experience prolonged symptoms, it is best to include screening for mood symptoms, as they are the most common predictor. While assessment tools and images can be helpful, clinicians should be confident and secure in their reporting of concussion assessment. The above-mentioned tools are effective, but care ultimately comes down to the knowledge of the healthcare provider.
After assessing and diagnosing a concussion, concussions need to be appropriately managed to promote optimal recovery. With a proper assessment, healthcare providers will have the information needed to tailor the management plan to each individual athlete. Management of concussion is no easy task. Thankfully, the care has moved away from a one-size-fits-all approach.
Concussions were traditionally managed with rest and “turning the brain off” or “cocooning”. There is no longer a passive approach; research shows that patients should be actively involved in their recovery. It is recommended that there be a brief period of rest. Rest usually lasts between 24 and 48 hours after the incident and consists of relative rest. Prolonged rest has actually been shown to lead to fatigue, reactive depression, and physiological deconditioning (Ledoux et al., 2022). After this period, it is acceptable for some physical activity and some cognitive testing to occur, as long as symptoms do not exacerbate during testing. This will aid in the return-to-learn (RTL) and return-to-play (RTP) process. The International Concussion in Sport Group has most recently recommended establishing a precedent for a return-to-learn period before returning to play. After sustaining a concussion, symptoms may alter a student-athlete's experience with school and sports due to the cognitive demands. Healthcare providers should have policies and procedures in place to meet the needs of athletes who sustain a concussion (Patricios et al., 2023a).
The return-to-learn process is a 4-step transition to full-time school attendance with no additional academic support, allowing the student-athlete to regain their pre-injury status. If there are any exacerbated symptoms that increase by more than 2 points on a 0-10 point scale for less than an hour, the athlete can proceed to the next step.
Return to Learn Process (Broglio et al., 2024; Patricios et al., 2023a)
Relative Rest and Daily Activities: After an initial period of relative rest (24-28 hours post-injury), the athlete may begin a gradual increase in their cognitive load. The focus is on symptom-free daily living and performance of activities that do not result in more than a mild/brief exacerbation of symptoms related to the current concussion. Activities such as reading, 5-15 minutes at a time, with gradual increases in time. Screen time should be minimized.
School Activities: Performance of activities such as homework, reading, or other cognitive activities outside the classroom.
Return to School Part-Time: Gradual introduction of schoolwork, maybe with a partial school day or greater access to rest breaks during the day.
Return to School Full-Time: Gradual progress in school activities until a full day can be tolerated without more than mild symptom exacerbation.
Return-to-learn can be influenced by demographics, personal or family history, initial symptoms, and academic setting. Jo et al. (2023) reported that collegiate athletes had a longer return-to-learn period than middle and high school athletes. This is likely due to the fact that college athletes have a more robust medical team to navigate their care. Having an interprofessional concussion management team has been shown to shorten return-to-learn and help with recovery of concussions (Kenrick-Rochon et al., 2021). The interprofessional concussion management team comprises a diverse group of healthcare professionals, including athletic trainers, physicians, physical therapists, nurses, neuropsychologists, and academic stakeholders such as patients, their families, teachers, and school administrators. One study found that the trust and knowledge of interprofessional concussion management team members increased over time. While the interprofessional concussion management team was helping treat concussions, they were also able to integrate and grow their interprofessional skills. With concussions affecting all aspects of a student, the team caring for them should have a breadth of knowledge to help navigate the athlete. In the absence of an interprofessional concussion management team, the student-athlete may be left to navigate care on their own. The student-athlete will have experienced a reduction in cognitive functions. Having an interprofessional concussion management team can help alleviate the cognitive burden of communicating with each stakeholder.
Williamson et al. (2018) reported that a majority of ATs had a return-to-learn policy; however, 30% were not aware that academic accommodations are an option available for injured student-athletes. The ATs are often seen as the primary healthcare providers for concussion management on a day-to-day basis, and should be informed, interact with, and intervene with all stakeholders to help adjust academic accommodations.
Students may recover with just informal academic assistance. This may include reduced hours at school, more time to complete assignments, frequent breaks, less screen time, and/or working in a less noisy area. The healthcare provider may want to have a standard letter to help communicate the need for reintegration into the classroom. While not legally binding, Purcell et al. (2019) reported that when a healthcare provider provided an accommodation letter, student-athletes were more likely to receive accommodations. Research has shown that 93% of athletes who sustain a concussion are able to return to learn within 10 days (Patricios et al., 2023a).
If symptoms persist for more than 14 to 28 days, healthcare providers should be familiar with and seek legal documentation, such as a 504 plan or an Individualized Education Program (IEP). These plans help protect students from discrimination based on their injuries or disabilities that can be due to a concussion (Williamson et al., 2018). These plans help protect students from discrimination based on their injuries or disabilities that can be due to a concussion.
Due to a decrease in cognitive function after sustaining a concussion, athletes' attendance and their academic performance declined. Covassin et al. (2024) found that athletes who did not receive their initial concussion evaluation from an AT had more missed school days, demonstrating that a return-to-learn process is of paramount importance and highlighting the importance of having guidance from a healthcare provider throughout the process.
The return-to-play process is also important, and is similar to the return-to-learn process. While every athlete, parent, or coach might ask, “When will they be back to playing?” or “How long will they be out of competition?” It is essential to note that healthcare providers may not know the exact time. Most injuries are not one-size-fits-all, and a concussion is no exception to this rule; however, most athletes return to play within 2 to 4 weeks. This is dependent on preinjury factors and postinjury predictors (Wang et al., 2022). Preinjury factors are things such as: history of concussion, sex, age, learning disability, and genetics. Postinjury factors include the number of symptoms present at the initial evaluation and the severity of these symptoms. Delay in care or access to a healthcare provider is also associated with longer recovery (Haarbauer-Krupa et al., 2018). Wang et al. (2022) also reported an interesting finding that athletes in individual sports had longer return-to-play times than those in team sports. While having an exact timeline may seem detrimental, it can be helpful to healthcare providers in determining whether an athlete requires additional resources or is at risk for a prolonged return-to-play period. If symptoms worsen or fail to resolve, a referral for rehabilitation is recommended. This will be discussed later in the course.
The return-to-play decision is a comprehensive process consisting of six steps, known as a graded stepwise strategy. Return-to-play can begin as soon as return-to-learn is initiated. Return to play is complete when no symptoms occur with maximal physical exertion. Similar to the return-to-learn, each step should be completed without an increase of symptoms by 2 points on a 1-10 point scale. These symptoms should last less than an hour. If symptoms persist beyond mild and brief, the athlete should stop and attempt that step after 24 hours. Each step should take a minimum of 24 hours without increased symptoms before proceeding to the next step (Patricios et al., 2023a).
Return to Play Process (Broglio et al., 2024; Patricios et al., 2023a)
Symptom-limited Activity: Daily activities that do not exacerbate symptoms, such as walking. Gradual reintroduction of work and school.
Aerobic Exercise: Starting with Light (< 55% max heart rate), then progressing to Moderate (< 70% max heart rate). Activities include stationary cycling or walking at a slow to medium pace. Light resistance training that does not exacerbate symptoms. This phase will show how the athlete is affected by gradually increasing the heart rate.
Individualizes Sport-Specific Exercise: Sport-specific training away from the team environment (running, change of direction, individual training drills). No activities that involve head impact. NOTE: If sport-specific training involves a risk of any inadvertent head impact, medical clearance should be obtained before proceeding to step 3.
Noncontact Training Drills: Exercise to high intensity, including more challenging training drills that can integrate into a team environment. This allows for a return to the usual intensity of exercise and coordination, while also increasing cognitive components.
Full-contact Practice: Participation in normal training activities. This restores confidence and assesses functional skills by the coaching staff.
Return to Sport: Normal game play
This approach provides healthcare providers with a standardized management protocol. This protocol can often be challenging. As previously reported, ATs have voiced the pressure from coaches, parents, and students. Another barrier was the lack of standardization, which allows for variation in return-to-play (Stavitz 2023). Steps 4-6 should be monitored by a healthcare provider. The addition of a 6-step graduated return-to-play protocol enables healthcare providers to safely and gradually reintroduce an athlete to sport. Lempke et al. (2020) reported that ATs were most likely to use the return-to-play guidelines 91% of the time and were the primary decision makers for return-to-play 72% of the time when an athlete was ready to return to competition (Lempke et al., 2020; Wallace et al., 2017). The governing board for athletic trainers and the scope of practice in many states recognize ATs in return-to-play decisions. Athletic trainers are authorized to clear athletes for return to participation in 40/50 of the states (Potteiger et al., 2018).
While ATs are most frequently involved with the return-to-play decision-making process, if schools do not have an AT on site, school nurses, physical therapists specializing in sports, and primary care physicians should be encouraged to assist with the return-to-play process. Carson et al.'s (2014) study found that athletes were prematurely returning to play after visiting a physician. This was reiterated in a more recent study, which found that physicians were most likely to assess symptoms only before making a return-to-play decision (Miller et al., 2025). Only healthcare providers who are trained in the evaluation and management of concussions and return-to-play policy should be included. Research has shown that most parents rely on what physicians and healthcare providers declare regarding concussion information (Kerr et al., 2022). Exposing healthcare providers to concussion research and education enables more accurate diagnoses, a safer return to learning and sports, and the sharing of knowledge with patients (Daly et al., 2022).
Some states have laws that dictate parameters of the return-to-play protocol. For instance, in Texas:
A medical professional must evaluate the athlete, and their clearance is required before beginning any RTP protocol.
Symptom-free at rest and exertion for at least 24 hours before starting RTP protocol
Progressive steps with at least 24 hours between each step
Physician-written clearance to return to full game participation
School districts are required to have concussion oversight teams with at least one physician.
Sometimes the management of a concussion is not within the standards of normal recovery. These athletes may sometimes require an alternative approach. When athletes are suffering from a subtype of concussion, based on symptoms, they will benefit most from vision or oculomotor-specific therapies. A vestibular impairment can manifest as defects in balance function, as well as visual and spatial orientation. This is necessary for the muscle reactions of the head and body to maintain balance and gait. Oculomotor impairment can present as blurred vision, diplopia, eyestrain, difficulties with visual scanning, and headaches. It is essential for healthcare providers to understand what is limiting the athlete's recovery. Vestibular and ocular-motor problems can be debilitating and slow down the recovery process (Master et al., 2022). Referrals to specialists, such as vestibular physical therapists or neuro-optometrists, who can treat these subtypes of concussion symptoms are on the rise. Treatment of post-concussion vestibular symptoms or impairments leads to greater clinical improvements than behavioral management alone (Eagle et al., 2023).
Sometimes, athletes may need to utilize medication for the treatment of a concussion; however, there are no approved medications for the treatment of concussions. Healthcare providers can help patients effectively use medications to manage specific symptoms. With headaches associated with a concussion, clinicians should focus on other causes before prescribing medication. After ruling out cervical dysfunction, dehydration, poor nutrition, stress, allergies, and the menstrual cycle, the healthcare provider should focus on which type of headache athletes are suffering from. It is safe to use non-steroid anti-inflammatory drugs (NSAIDs) and acetaminophen to treat headaches, with caution for long-term use of NSAIDs due to the risk of rebound headaches. For migraine-like postconcussive headaches, patients can be prescribed tricyclic antidepressants and antiepileptics. Side effects of prescribed tricyclic antidepressants can cause drowsiness, emotional stress, palpitations, and orthostasis. Athletes should also be ruled out for any cardiac abnormalities due to the risk of tricyclic antidepressants and arrhythmia. Valproic acid, topiramate, and gabapentin have all been shown to help with postconcussive headaches and migraine. Beta-blockers are also used, but more for migraine prophylaxis. The side effects of beta-blockers can potentially exacerbate symptoms of depression. Benzodiazepines and atypical GABA agonists should be avoided during concussion recovery. The effects of cognitive decline and judgment can be shown after taking these medications. When addressing sleep deficiencies, melatonin, sleep hygiene tips, and cognitive behavioural therapy (CBT) are effective recommendations for healthcare providers. Most often, otolaryngology specialists or ocular specialists may prescribe memantine, beta-blockers, betahistine, and oxcarbazepine for oculomotor and vestibular disorders following a concussion. Whenever patients are using medication to help alleviate symptoms, healthcare providers should be aware of this before clearing athletes for return-to-learn or return-to-play. Athletes should have resolved symptoms without medication to be considered for potential return to contact sports (Jones & O’Brien, 2021).
For supplements, magnesium can be a good option in reducing the severity and frequency of migraine headaches (Jones & O’Brien, 2021). Magnesium oxide is the form of magnesium most commonly associated with diarrhea as a side effect. Athletes should use caution when taking additional magnesium. Riboflavin, also known as Vitamin B2, is used for migraine prevention, with some remedies, including coenzyme Q10, alpha-lipoic acid, and butterbur, shown in research to prevent migraines. Another supplement that can be helpful is omega-3 fatty acids. The omega-3 fatty acid, docosahexaenoic acid (DHA), has the most research, as it is predominantly found in the membranes of neurons. There are some reports saying it could improve cognition impairments following a concussion or benefit learning disabilities and depression (Miller et al., 2019). Side effects also include looser stools, reflux, and nausea.
If treatment of concussions persists, healthcare providers should be aware of the medical disqualification (MDQ) process. While medical disqualifications are common, they are most seen in non-concussion cases. Most athletes return to play following a concussion (Schmidt et al., 2020b). If an athlete requests a medical opinion regarding a potential medical disqualification, healthcare providers should be open to discussing this matter. There are misconceptions about the ‘magic number’ of concussions an athlete can be diagnosed with. Previous research suggested that athletes with three diagnosed concussions should retire from their sport. This recommendation, along with others such as diminished academic performance, prolonged recovery, and abnormal neuroimaging, was once thought to disqualify athletes from participating in sports. However, those are all based on clinical opinion, and there is no confirmed evidence that certain factors lead to a retirement or discontinuation of sport (Patricios et al., 2023a). Research by Schmidt et al. (2020b) indicates that several factors can increase the likelihood of medical disqualification. First, healthcare providers should be aware of the number of previous concussions. 32.1% of athletes reported medical disqualification after just two total concussions. Clinicians should objectively evaluate each concussion to make sure that no further risk is taken when returning an athlete to activity. Having misconceptions and medical biases has no part when informing a patient about a medical disqualification. Another factor that healthcare providers should be aware of is the severe presentation during the initial presentation of a concussion. It is well researched that the more symptoms an athlete has, the longer their recovery is following a concussion (Patricios et al., 2023a). This then takes into effect the factor for the recovery process after sustaining a concussion. Athletes who struggle to recover also have a higher chance of medical disqualification following a concussion. This same research from Schmidt et al. (2020b) discovered that athletes were positive for medical disqualification when there were mental health alterations, substance use, and motivation issues. Medical disqualification is a shared decision between an athlete and/or their guardian or parent and healthcare providers. Only healthcare providers with experience in traumatic brain injuries should talk about medical disqualification. It is also recommended to have adequate psychological support and follow-up. Athletic identity is complex, and the consequence of losing that identity is an increased risk for mental health symptoms and disorders (Makdissi et al., 2023). Athletes with a strong athletic identity often struggle to cope following an injury. Reports show that depression, behavioral, and social issues increase after an injury (Renton et al., 2021). Sidelined USA, a 501(c)3 nonprofit, is a company that reunites permanently sidelined athletes with their passions and inspires them to find a meaningful way forward(Sidelined USA, n.d.). They have a wealth of resources and materials available for athletes, healthcare providers, and parents to utilize during this new chapter.
Ten-year-old Melanie was presented to the sideline after taking a contact fall while playing a youth league soccer game. Melanie’s coach noticed the incident and reported it to the athletic trainer (AT) on site. The AT used the Post-Concussion Symptom Inventory for Children (PCSI-C). Melanie reports experiencing two symptoms: a headache and sadness, with a severity score of 5. The patient was not allowed to continue to return to activity. The AT then performed a comprehensive assessment using the Child SCAT6. This revealed that Melanie was having troubling neck pain with a limited range of motion. Upon questioning, it was discovered that the neck pain started yesterday, after going to her best friend's birthday party. The party was at the local trampoline center. With all the factors, Melanie was recommended to follow the concussion management protocol. Because Melanie is not an athlete that the AT sees on a regular basis, the patient was provided with numerous educational materials and resources to utilize. Melanie's parents were given educational material on how to manage a child with a concussion. The coach was then informed of the process to return to play. The athletic trainer shared their contact information and, if needed, the physician group appointment number with both the coach and parents. The athletic trainer was also able to share the details of the return-to-learn protocol. This also included a letter stating that Melanie has symptoms that may warrant academic accommodations. With the quick action of the coach and the prompt assessment by the AT, Melanie did not require a return-to-learn protocol and was able to participate in the return-to-sport protocol. Melanie was able to fully return to sport within two weeks.
It is imperative that discussions on concussion include the topic of prevention strategies. Prevention strategies must involve public education to increase concussion awareness. Prevention should also involve the governing board of each sport and organization. Healthcare providers should be aware of the rules, laws, and policies that govern their practice. New policies and rule modifications have been shown to reduce or prevent concussions.
Health literacy is an important factor in informing the public about this crisis. Concussion education should start prior to a student-athlete getting diagnosed with a concussion. All Healthcare providers should do their best to explain the complexity of concussions and the impact it has on sports. When done well, concussion education will enhance concussion knowledge, leading to positive behavior toward concussions. It was noted that children and youth had limited concussion knowledge or significant gaps in their knowledge, indicating the need for concussion education (Ramsay & Dahinten, 2020). A report by Daneshvar et al. (2021) showed an increase in youth athletes reporting a concussion to an adult after receiving concussion education. Another report found that only 80% of collegiate student-athletes had concussion-education exposure (Callahan et al., 2021). These results should stress the importance that healthcare providers should not assume athletes are knowledgeable about concussions due to age or long-term exposure to sports.
Concussion education is not just for the athlete; parents and guardians should also be informed, as they will often play a big role in navigating the concussion process. Research from Rice & Curtis (2019) showed that only 44% parents received concussion education prior to their child’s participation in club sports. This knowledge gap can place athletes at risk. Concussion education should be provided to all stakeholders, including athletes, parents/guardians, sports coaches, school professionals, teachers, healthcare providers, and even sports officials. As recommended by the International Consensus Statement on Concussion in Sport, concussion education should be provided to all individuals within the school (Patricios et al., 2023a). The three most common delivery methods are in-person and self-directed online modules, with or without a supported instructor. It should be observed that the delivery method did not matter in many cases. There is proof that athletes with concussion education were more likely to report suspected concussions, regardless of the method of delivery (Daneshvar et al., 2021); however, there were more favorable outcomes when the concussion material was engaging. Research by Kolberg et al. (2021) involved creating comic book illustrations and video content for the distribution of concussion discharge instructions. The results of this study showed that patients demonstrated an increase in their knowledge of concussions. This novel idea should be encouraged in the sports setting. It is the job of the health care team to know their setting and be aware of which means of concussion education would be effective.
Unfortunately, there is no standard on what should be included in concussion education. Most educational materials included signs and symptoms, medical management, definitions, return-to-school considerations, and long-term effects. Recommendations from Mallory et al. (2022) include focusing the concussion education on the student setting, tailoring it to your delivery style, providing education to all individuals within the school, meeting the goals and outcomes of the education, making sure it is culturally relevant and applicable, and that it reflects the current evidence.
Given that concussion is a public health concern, one of the most reliable sources of educational material is the Centers for Disease Control and Prevention (CDC). The CDC, the national public health agency of the United States, has material specific to each stakeholder who may be affected by a concussion. In 2003, the HEADS UP campaign was launched to raise public awareness about concussions. Concussions should be diagnosed quickly, and medical care should not be delayed. Often, however, this can be the opposite if each stakeholder is not educated or informed on the matter. This, in turn, can slow the recovery process for student-athletes. Research shows that patients who delay reporting their concussion take longer to recover (Barnhart et al., 2021). Additionally, by educating stakeholders, each person understands their specific role and the role of their collaborating partners. There should never be a question about who has the medical authority to remove and return an athlete. In return, this helps reduce conflicts of interest when a situation may arise. Reports from Kroshus et al. (2015) presented that athletic trainers had experienced pressure to prematurely return athletes to play following an injury. These external factors should never take precedence over the well-being and care of the student-athlete. It is the job of every individual who interacts with a sports population to increase their knowledge of concussions. Education should focus on prevention measures, mechanisms, recognition, referral policies, return-to-participation guidelines, physical and cognitive limitations, and the misuse of concussion management (Broglio et al., 2024).
Concussion education is also important because it is required by law. All 50 states and the District of Columbia have required some form of concussion education or awareness training since 2009. Stakeholders should evaluate their sports organization to ensure it is following state law mandates. Athletic trainers should be reminded of their professional standard of care. This standard compels the professional to exercise the care, skill, and diligence that would be exercised by a member of that profession in good standing (Rapp & Ingersoll, 2019). The act of omission can be considered negligence or a failure to meet the standard of care, resulting in injury (Potteiger et al., 2018).
Each state has certain concussion legislation that is required of it. Most states require a signed consent form from student-athletes, parents, and coaches. However, only 22 states include education for game officials. The majority of states also require educational training for coaches. The requirement on how often coaches should be required is not standard. Sixteen states do not specify a timeframe for repeating training, whereas 15 states require yearly training.
It is the responsibility of each organization to obtain concussion education material. While most educational training is delivered through handouts or online courses, it may not be as effective as in-person training. Educational strategies should extend beyond the transmission of passive information. Additionally, the theory presented by Kerr et al. (2018) suggests that key behavioral changes in a population can spread to others if enough opinion leaders adopt, endorse, and support the behavior. While concussion education is mandated, it is important for ATs to be change makers. This oftentimes means including all stakeholders, especially coaches. Fostering consistent communication in support of concussion safety may lead to increased reporting of concussions (Baugh et al., 2020). A coach’s behavior toward concussion safety may mirror that of students-athletes seeking medical care. (Schmidt et al., 2020a) Concussion education should not just be a checklist requirement. Every individual has a duty to keep student athletes safe. An AT may not be present for all athletic practices and events, so the responsibility for safety will lie with the coaches. It is the duty of healthcare providers to advocate, educate, and serve as change agents for the safety and protection of all people (Potteiger et al., 2018). Concussion education to all stakeholders should be used as one of the ways to help with concussions.
Sport policy changes have been implemented in many sports to help prevent concussions. New policy changes in ice hockey that disallow body checking were shown to reduce concussions by 58%. Ice hockey also had lower odds of concussion when teams did not commit a penalty within a specified time frame. A rule change in professional baseball saw a reduction in catchers sustaining a concussion. This rule limited collisions between base runners and catchers. An uptake in tackle football research has led to new policies and a reduction in concussions. One new implementation demonstrated that restricting contact time during practice resulted in reductions in concussions (Pfaller et al., 2019). This study went on to show a 57% reduction in high school football players sustaining a concussion at practice, with no marginal difference in concussions during competition. Concussions are more commonly seen in competition than in practice. To reduce competition concussions, the implementation of a new kickoff placement has been enforced. Kickoffs are known to be the most dangerous play in football. With new policies that were implemented, moving the kickoff line up saw a reduction in concussions at the college football level. Other studies showed a decrease in concussions when proper tackling education and prohibiting targeting were implemented. Targeting is when an athlete makes forcible contact with the crown of the helmet or makes forcible contact with the head or neck of a defenseless opponent. One study showed that there was a 37% higher chance of college football players sustaining a concussion during a targeting play (Aukerman et al., 2022). This is reflected in Obana et al. (2021), who report a decrease in helmet-to-helmet diagnosed concussion after implementing the targeting rule in high school football. These policy changes focus on the integrity of the game and the safety of its athletes.
While there is no concussion-proof helmet, the CDC recommends using a helmet to protect against concussions. While wearing a helmet cannot prevent a concussion, wearing a properly fitted helmet has been shown to absorb impact forces and reduce the risk of skull injuries. Helmets, however, cannot control the brain’s acceleration and deceleration forces (concussion.org, 2020). Approved helmets for tackle football and ice hockey were shown to reduce the concussion rate by 31%. The National Operating Committee on Standards for Athletic Equipment (NOCSAE) is an independent standards development body that is the leading force in the effort to improve athletic equipment. This entity develops performance and test standards for football helmets and facemasks, baseball and softball batter’s and catcher’s helmets, ice hockey helmets, lacrosse helmets, field hockey headgear, and other safety products (National Operating Committee on Standards for Athletic Equipment, 2018). Many organizations, such as the National Football League (NFL), the National Collegiate Athletic Association (NCAA), the National Federation of State High School Associations (NFHS), and the United States Department of Defense Education Activity, require specific pieces of equipment to be certified by NOCSAE. Healthcare providers should ensure that the equipment meets the NOCSAE standards. It should be noted that after 10 years of use, the helmet will no longer be able to be recertified for safety purposes.
The use of mouthguards is mandatory for football, field hockey, ice hockey, lacrosse, and wrestling. Mouthguards are required to help minimize oral and facial injury. While research currently does not support the theory that mouthguard minimizes the risk or severity of concussion, mouthguard use was associated with a 26% decrease in the rate of concussion (Chisholm et al., 2020). This decrease was only significant for youth athletes who played ice hockey. While the use of mouthguards is mandatory for these collision sports, it is a beneficial habit for young athletes to wear mouthguards, given their potential for protecting against concussions. One study reported that more than 90% of college ice hockey teams believed that wearing a mouthguard was vital for preventing concussions (Mihalik et al., 2007).
A newer topic is the addition of the Guardian Caps. These aftermarket add-on shell devices go on top of the helmet. These Guardian Caps came into popularity after the NFL introduced them in 2022. Guardian Caps were shown to have mixed reviews when studied in the laboratory. Research by Hammer et al. (2025) aimed to investigate the efficiency of Guardian Caps in high school football athletes. The study found that athletes who wore Guardian Caps showed no decreased risk of concussion during practice. The study also highlighted that there was no difference in initial symptoms following a concussion or in the time it took to return to sport between athletes who wore Guardian Caps and those who did not. Interestingly enough, the study showed that athletes who wore a Guardian Caps during practice had a higher rate of sustaining a concussion during competition. This implied that athletes may play more aggressively during competition because they felt protected wearing the Guardian Caps.
Similar to soft-sided helmet coverings, another type of soft-sided headgear that has gained popularity is the concussion headband. These headbands are popular in sports that do not require the use of a helmet, such as soccer, women’s lacrosse, and many other field sports. Despite manufacturers’ and early research claims of efficacy, evidence indicates that soft-sided headgear does not reduce the rate of sport-related concussions (Knight et al., 2021; McGuine et al., 2019). Despite the evidence, some physicians still recommend them to patients.
Another wearable device is the Jugular Vein Compression Collar. This device was theorized after research found that decreasing ‘sloshing’ of the brain helped mitigate brain injury. The idea is that an increase in the amount of blood in the brain would not allow for much brain ‘sloshing’ around. Additionally, maintaining higher venous pressure resulted in an 80% decrease in amyloid protein precursor in rats. Amyloid protein plays a crucial role in maintaining brain health and is utilized in the treatment of neurodegenerative diseases. While there is no reduction in concussions noticed from wearing a Jugular Vein Compression Collar, research has shown potential protection against changes in white matter as a result of concussions. Participants who did not use a Jugular Vein Compression Collar were found to have significant white matter alterations when comparing pre-season and post-concussion neuroimaging, defects that may contribute to symptoms such as slow processing and emotional changes (Narad et al., 2022). Another deficiency discovered was the decrease in water that traveled to the nerve axons, which can indicate nerve damage and degeneration. The major factors reported by the Jugular Vein Compression Collar group included faster cognitive function, as measured by the King-Devick test (Yuan et al., 2021), and an increase in the Attention Network Task scores (Narad et al., 2022). The Jugular Vein Compression Collar may be one way to help mitigate the long-term effects of a concussion.
While there is a need to prevent concussions, stakeholders should be cautious if results are not indicated by research for their suggested sport population. Healthcare providers should prioritize evidence-based research that impacts the safety of the athlete. These studies demonstrate strong evidence to support concussion prevention. The most significant prevention measures can be achieved by implementing certified helmets, enacting state laws, and adhering to official sports rules, while also involving stakeholders in the prevention strategy and providing proper training and education to coaches. Healthcare providers should express their concerns to their government representatives and the sport’s governing body to ensure that laws and policies are enforced to help prevent concussions.
It is proposed that athletes should be able to see peripherally to be prepared for collision sports. An athlete who is limited by vision may be at risk for a concussion. Good vision and sensorimotor skills are essential for reducing head impacts. A recent study demonstrates the benefits of vision training in reducing concussion risk. This research has only been reported in high school ice hockey (Kiefer et al., 2018) and college football players (Harpham et al., 2014). Using visual and sensory performance assessment tools to determine deficits following a concussion may enable clinicians to incorporate another tool into more sport-relevant return-to-play guidelines (Harpham et al., 2014). One issue this study highlights is that visual training may be best suited for experienced players. Focusing on visual cues and preparing for impact may be necessary prior to visual training interventions. Further research is needed to determine if visual training positively affects all sports populations in reducing concussions.
Another way for all athletes to reduce concussions is through neck strength. Neck strength is responsible for maintaining posture and stabilizing the head at rest. Neck stiffness helps reduce the translation of head displacement along with velocity and acceleration (Silverman et al., 2024). With neck strengthening and the ability to contract the neck quickly, it is believed to give enough time for athletes to brace for a collision. A study by Attwood et al. (2018) reported a 60% lower incidence of concussions in rugby athletes who completed weekly neck strength and conditioning programs. Research found that for every pound of neck strength gained by athletes, the odds of sustaining a concussion decreased by 5%.
Stakeholders should encourage neck strength training to help reduce the risk of concussions. However, there may be financial barriers to measuring neck strength, as the cost of a handheld dynamometer to measure neck strength is approximately $ 1,000.
Healthcare providers should implement balance training. While neuromuscular training is often used for lower extremity injuries, it has shown benefits in reducing concussions. Research discovered that poor balance was shown to be a risk factor for sustaining a concussion. One study had ATs and strength coaches collaborate on a 10-week preseason training program focusing on mobility, agility, stability, strength, and flexibility in high school athletes, which was shown to decrease risk of concussions (Morrissey et al., 2019). This study highlights the need for healthcare providers to implement training programs to enhance their dynamic balance and movement skills. Exercise warm-up programs that incorporate multiple components (e.g., balance, resistance, landing, and cutting) have been shown to reduce concussion rates and are recommended (Eliason et al., 2023). Since injuries, such as a concussion, are unpreventable, healthcare providers should do their best to limit the rate. Adding prevention strategies, such as neck strengthening and balance training, is a proactive approach that can be useful when discussing concussions.
Concussions can inhibit several neurophysiological tasks, with some reporting defects up to a year after concussion symptoms have resolved. Focus on protecting the brain, and its functional measures are in place; however, new research is showing that kinematic measures should also be included in return-to-play protocols. Measures of decreased maximum strength, impaired neural activity, poor postural stability, and sensorimotor impairments are all factors that can contribute to a musculoskeletal injury (Chmielewski et al., 2021). The most recent study from Jildeh et al. (2022) demonstrates that athletes returning to play from a concussion have an elevated risk of lower extremity injuries within 3 months to a year. Another study reported that athletes with a concussion had a 2.11 times greater odds of sustaining a musculoskeletal injury compared to non-concussed athletes (McPherson et al., 2019). With this information, healthcare providers should ensure that athletes are prepared for their return to play from both a cognitive and neuromuscular readiness standpoint. Screening for neuromuscular risk factors should be incorporated into return-to-play protocols when managing athletes who have sustained a concussion. Additional rehabilitation may be necessary to address limitations and impairments. These deficits may impact the return-to-play timeline.
Another concern following a concussion is overall brain health, with studies examining chemical and structural changes that can occur following a concussion. Evidence supports that physical trauma can have effects on cognition, mood, and motor function (Howlett et al., 2022). Research has shown through testing that brain alterations can occur even when the athlete appears symptom-free (Patel et al., 2024). One particular neurological change that has garnered a lot of attention is chronic traumatic encephalopathy (CTE). This condition is a neurodegenerative disorder thought to be due to repetitive head injury, with repeated head injury as the only known unifying factor (Munakomi & Puckett, 2024). While CTE causation has some strong disagreements, the lingering issue is the inability to diagnose it during a person's lifetime (Kelly et al., 2023; Belson, 2022). CTE is only diagnosed postmortem when clinicians identify a pathognomonic lesion. It should be mentioned that only one lesion is needed to diagnose CTE. This is met with some criticism, as this does not correspond with clinical symptoms. It is efficient to minimize repetitive head trauma by having standards in place to create a safe environment. Preventive measures are taken when early diagnosis of concussions, and following the return-to-play and return-to-learn, are used to combat harmful changes to the brain.
Sports-related concussions are a complex injury, involving many physiological paths and affecting many different populations. With the uprising in cases, it is considered a public health issue. Advancements in multi-domain assessments, neurocognitive tests, the specialization of treatment, and biomarkers are on the horizon. It takes healthcare providers who are willing to educate themselves and grow their clinical skills to advance these matters. It is believed that it takes approximately 17 years for research to meet clinical practice. Healthcare providers should be closing that gap by utilizing their knowledge, ensuring that athletes are given the best care for sport-related concussions. Much research is still needed for athletes with disabilities, females, and even children. Healthcare providers are recommended to investigate how concussion affects their population of athletes. Concussion management is no easy job. It takes risk reduction and health literacy, a thorough evaluation, clinical management skills, therapeutic interventions, interpersonal skills, and continuing education to take care of student-athletes suffering from a concussion. Healthcare providers should work together as a team to ensure the athlete's needs are met.
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CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
Attwood, M. J., Roberts, S. P., Trewartha, G., England, M. E., & Stokes, K. A. (2018). Efficacy of a movement control injury prevention programme in adult men's community rugby union: A cluster randomised controlled trial. British Journal of Sports Medicine, 52(6), 368–374. Visit Source.
Aukerman, D. F., Bohr, A. D., Poddar, S. K., Romano, R., Petron, D. J., Ghajar, J., Giza, C. C., Lumba-Brown, A., McQueen, M. B., & Harmon, K. G. (2022). Risk of concussion after a targeting foul in collegiate American football. Orthopaedic Journal of Sports Medicine, 10(2), 23259671221074656. Visit Source.
Barnhart, M., Bay, R. C., & Valovich McLeod, T. C. (2021). The influence of timing of reporting and clinic presentation on concussion recovery outcomes: A systematic review and meta-analysis. Sports Medicine, 51(7), 1491–1508. Visit Source.
Baugh, C. M., Kroshus, E., Meehan, W. P., & Campbell, E. G. (2020). Trust, conflicts of interest, and concussion reporting in college football players. The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics, 48(2), 307–314. Visit Source.
Becker-Haimes, E. M., Tabachnick, A. R., Last, B. S., Stewart, R. E., Hasan-Granier, A., & Beidas, R. S. (2020). Evidence base update for brief, free, and accessible youth mental health measures. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 49(1), 1–17. Visit Source.
Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., Fernandez, T., & Mandell, D. S. (2015). Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cognitive and Behavioral Practice, 22(1), 5–19. Visit Source.
Belson, K. (2022). Scientists say concussions can cause a brain disease. These doctors disagree. The New York Times. Visit Source.
Broglio, S. P., Register-Mihalik, J. K., Guskiewicz, K. M., Leddy, J. J., Merriman, A., & Valovich McLeod, T. C. (2024). National athletic trainers' association bridge statement: Management of sport-related concussion. Journal of Athletic Training, 59(3), 225–242. Visit Source.
Callahan, C. E., Kay, M. C., Kerr, Z. Y., Hinson, M. T., Linnan, L. A., Hennink-Kaminski, H., Gildner, P., Marshall, S. W., Houston, M. N., Cameron, K. L., & Register-Mihalik, J. (2021). Association between previous concussion education and concussion care-seeking outcomes among National Collegiate Athletic Association Division I student-athletes. Journal of Athletic Training, 56(3), 294–301. Visit Source.
Carson, J. D., Lawrence, D. W., Kraft, S. A., Garel, A., Snow, C. L., Chatterjee, A., Libfeld, P., MacKenzie, H. M., Thornton, J. S., Moineddin, R., & Frémont, P. (2014). Premature return to play and return to learn after a sport-related concussion: Physician's chart review. Canadian Family Physician, Médecin de Famille Canadien, 60(6), e310–e315. Visit Source.
Chandran, A., Kerr, Z. Y., Roby, P. R., Nedimyer, A. K., Arakkal, A., Pierpoint, L. A., & Zuckerman, S. L. (2020). Concussion symptom characteristics and resolution in 20 United States high school sports, 2013/14-2017/18 academic years. Neurosurgery, 87(3), 573–583. Visit Source.
Chisholm, D. A., Black, A. M., Palacios-Derflingher, L., Eliason, P. H., Schneider, K. J., Emery, C. A., & Hagel, B. E. (2020). Mouthguard use in youth ice hockey and the risk of concussion: Nested case-control study of 315 cases. British Journal of Sports Medicine, 54(14), 866–870. Visit Source.
Chmielewski, T. L., Tatman, J., Suzuki, S., Horodyski, M., Reisman, D. S., Bauer, R. M., Clugston, J. R., & Herman, D. C. (2021). Impaired motor control after sport-related concussion could increase risk for musculoskeletal injury: Implications for clinical management and rehabilitation. Journal of Sport and Health Science, 10(2), 154–161. Visit Source.
Concussion.org. (2020). Football helmet misconceptions: Q&A. Visit Source.
Covassin, T., Pollard-McGrandy, A. M., Klein, L. A., Wiebe, D. J., & Bretzin, A. C. (2024). Missing school days following sport-related concussion in high school athletes. JAMA Network Open, 7(10), e2440264. Visit Source.
Daneshvar, D. H., Yutsis, M., Baugh, C. M., Pea, R. D., Goldman, S., Grant, G. A., Ghajar, J., Sanders, L. M., Chen, C. L., Tenekedjieva, L. T., Gurrapu, S., Zafonte, R., & Sorcar, P. (2021). Evaluating the effect of concussion-education programs on intent to report concussion in high school football. Journal of Athletic Training, 56(11), 1197–1208. Visit Source.
Daly, E., Pearce, A. J., Finnegan, E., Cooney, C., McDonagh, M., Scully, G., McCann, M., Doherty, R., White, A., Phelan, S., Howarth, N., & Ryan, L. (2022). An assessment of current concussion identification and diagnosis methods in sports settings: A systematic review. BMC Sports Science, Medicine & Rehabilitation, 14(1), 125. Visit Source.
Eagle, S. R., Mucha, A., Trbovich, A., Manderino, L., Elbin, R. J., Collins, M. W., & Kontos, A. P. (2023). Association of multidomain assessment outcomes with referral for vestibular therapy after concussion. Journal of Athletic Training, 58(5), 408–413. Visit Source.
Echemendia, R. J., Burma, J. S., Bruce, J. M., Davis, G. A., Giza, C. C., Guskiewicz, K. M., Naidu, D., Black, A. M., Broglio, S., Kemp, S., Patricios, J. S., Putukian, M., Zemek, R., Arango-Lasprilla, J. C., Bailey, C. M., Brett, B. L., Didehbani, N., Gioia, G., Herring, S. A., Howell, D., … Schneider, K. J. (2023a). Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: A systematic review. British Journal of Sports Medicine, 57(11), 722–735. Visit Source.
Echemendia, R. J., Brett, B. L., Broglio, S., Davis, G. A., Giza, C. C., Guskiewicz, K. M., Harmon, K. G., Herring, S., Howell, D. R., Master, C., McCrea, M., Naidu, D., Patricios, J. S., Putukian, M., Walton, S. R., Schneider, K. J., Burma, J. S., & Bruce, J. M. (2023b). Sport Concussion Assessment Tool 6 (SCAT6). British Journal of Sports Medicine, 57(11), 622–631. Visit Source.
Eliason, P. H., Galarneau, J. M., Kolstad, A. T., Pankow, M. P., West, S. W., Bailey, S., Miutz, L., Black, A. M., Broglio, S. P., Davis, G. A., Hagel, B. E., Smirl, J. D., Stokes, K. A., Takagi, M., Tucker, R., Webborn, N., Zemek, R., Hayden, A., Schneider, K. J., & Emery, C. A. (2023). Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis. British Journal of Sports Medicine, 57(12), 749–761. Visit Source.
Gowrisankaran, S., Shah, A. S., Roberts, T. L., Wiecek, E., Chinn, R. N., Hawash, K. K., O'Brien, M. J., Howell, D. R., Meehan, W. P., 3rd, & Raghuram, A. (2021). Association between post-concussion symptoms and oculomotor deficits among adolescents. Brain Injury, 35(10), 1218–1228. Visit Source.
Haarbauer-Krupa, J. K., Comstock, R. D., Lionbarger, M., Hirsch, S., Kavee, A., & Lowe, B. (2018). Healthcare professional involvement and RTP compliance in high school athletes with concussion. Brain Injury, 32(11), 1337–1344. Visit Source.
Haider, M. N., Nowak, A., Sandhur, M., & Leddy, J. (2022). Sport-related concussion and exercise intolerance. Operative Techniques in Sports Medicine, 30(1), 10895. Visit Source.
Hallock, H., Mantwill, M., Vajkoczy, P., Wolfarth, B., Reinsberger, C., Lampit, A., & Finke, C. (2023). Sport-Related concussion. Neurology Clinical Practice, 13(2). Visit Source.
Hammer, E., Mosiman, S., Joachim, M. R., Taylor, E., Cordum, A., Brooks, M. A., & McGuine, T. (2025). The association between Guardian Cap use during practices and sport-related concussion risk in high school American football players. British Journal of Sports Medicine, 59(4), 257–262. Visit Source.
Harmon, K. G., Whelan, B. M., Aukerman, D. F., Hwang, C. E., Poddar, S. K., DeLeo, A., Elkington, H. A., Garruppo, G., Holliday, M., & Bruce, J. M. (2024). Diagnosis of sports-related concussion using symptom report or standardized assessment of concussion. JAMA Network Open, 7(6), e2416223. Visit Source.
Harpham, J. A., Mihalik, J. P., Littleton, A. C., Frank, B. S., & Guskiewicz, K. M. (2014). The effect of visual and sensory performance on head impact biomechanics in college football players. Annals of Biomedical Engineering, 42(1), 1–10. Visit Source.
Herring, S., Kibler, W. B., Putukian, M., Solomon, G. S., Boyajian-O'Neill, L., Dec, K. L., Franks, R. R., Indelicato, P. A., LaBella, C. R., Leddy, J. J., Matuszak, J.,McDonough, E. B., O'Connor, F., & Sutton, K. M. (2021). Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: A consensus statement. British Journal of Sports Medicine, 55(22), 1251-1261. Visit Source.
Howlett, J. R., Nelson, L. D., & Stein, M. B. (2022). Mental health consequences of traumatic brain injury. Biological Psychiatry, 91(5), 413–420. Visit Source.
Iverson, G. L., Williams, M. W., Gardner, A. J., & Terry, D. P. (2020). Systematic review of preinjury mental health problems as a vulnerability factor for worse outcome after sport-related concussion. Orthopaedic Journal of Sports Medicine, 8(10), 2325967120950682. Visit Source.
Jackson, W. T., & Starling, A. J. (2019). Concussion evaluation and management. The Medical Clinics of North America, 103(2), 251–261. Visit Source.
Jildeh, T. R., Castle, J. P., Buckley, P. J., Abbas, M. J., Hegde, Y., & Okoroha, K. R. (2022). Lower extremity injury after return to sports from concussion: A systematic review. Orthopaedic Journal of Sports Medicine, 10(1), 23259671211068438. Visit Source.
Jo, J., Williams, K. L., Hill, T. M., Perry, G. M., Prosak, O. L., Amedy, A., Anesi, T. J., Terry, D. P., & Zuckerman, S. L. (2023). Return-to-learn after sport-related concussion: Does school level matter? Journal of Neurosurgery. Pediatrics, 32(2), 125–132. Visit Source.
Jones, J. C., & O'Brien, M. J. (2021). Medical therapies for concussion. Clinics in sports Medicine, 40(1), 123–131. Visit Source.
Kelly, J. P., Priemer, D. S., Perl, D. P., & Filley, C. M. (2023). Sports concussion and chronic traumatic encephalopathy: Finding a path forward. Annals of Neurology, 93(2), 222–225. Visit Source.
Kenrick-Rochon, S., Quesnele, J., Baldisera, T., Laurence, M., & Grenier, S. (2021). Does interprofessional concussion management improve recovery in varsity athletes? A year to year effectiveness-implementation hybrid study. Physical Therapy in Sport: Official Journal of the Association of Chartered Physiotherapists in Sports Medicine, 47, 32–39. Visit Source.
Kerr, Z. Y., Chandran, A., Nedimyer, A. K., Rothschild, A. E., Kay, M. C., Gildner, P., Byrd, K. H., Haarbauer-Krupa, J. K., & Register-Mihalik, J. K. (2022). Use of sport-related concussion information sources among parents of United States middle school children. Journal of Sport and Health Science, 11(6), 716–724. Visit Source.
Kerr, Z. Y., Register-Mihalik, J. K., Haarbauer-Krupa, J., Kroshus, E., Go, V., Gildner, P., Byrd, K. H., & Marshall, S. W. (2018). Using opinion leaders to address intervention gaps in concussion prevention in youth sports: Key concepts and foundational theory. Injury Epidemiology, 5(1), 28. Visit Source.
Kiefer, A. W., DiCesare, C., Nalepka, P., Foss, K. B., Thomas, S., & Myer, G. D. (2018). Less efficient oculomotor performance is associated with increased incidence of head impacts in high school ice hockey. Journal of Science and Medicine in Sport, 21(1), 4–9. Visit Source.
Knight, J. M., Nguyen, J. V. K., Mitra, B., & Willmott, C. (2021). Soft-shell headgear, concussion and injury prevention in youth team collision sports: a systematic review. BMJ Open, 11(6), e044320. Visit Source.
Kolberg, K., Larson, J., Almeida, A., Ichesco, I., Johnson, A., Van Tubbergen, M., Nagappan, B. S., Saleem, N., Cranford, J. A., & Hashikawa, A. (2021). The feasibility of using comic-based concussion discharge instructions: Gauging likeability and knowledge improvement among adolescents and parents. Pediatric Emergency Care, 37(12), e1603–e1610. Visit Source.
Kroshus, E., Garnett, B., Hawrilenko, M., Baugh, C. M., & Calzo, J. P. (2015). Concussion under-reporting and pressure from coaches, teammates, fans, and parents. Social Science & Medicine (1982), 134, 66–75. Visit Source.
Leddy, J. J. (2025). Sport-Related Concussion. New England Journal of Medicine, 392(5), 483–493. Visit Source.
Ledoux, A. A., Barrowman, N., Bijelić, V., Borghese, M. M., Davis, A., Reid, S., Sangha, G., Yeates, K. O., Tremblay, M. S., McGahern, C., Belanger, K., Barnes, J. D., Farion, K. J., DeMatteo, C. A., Reed, N., Zemek, R., & PERC PedCARE Concussion team (2022). Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial. British Journal of Sports Medicine, 56(5), 271–278. Visit Source.
Lempke, L. B., Schmidt, J. D., & Lynall, R. C. (2020). Athletic trainers' concussion-assessment and concussion-management practices: An update. Journal of Athletic Training, 55(1), 17–26. Visit Source.
Lumba-Brown, A., Yeates, K. O., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., Giza, C. C., Joseph, M., Broomand, C., Weissman, B., Gordon, W., Wright, D. W., Moser, R. S., McAvoy, K., Ewing-Cobbs, L., Duhaime, A. C., Putukian, M., … Timmons, S. D. (2018). Centers for Disease Control and Prevention Guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatrics, 172(11), e182853. Visit Source.
Mack, C., Myers, E., Barnes, R., Solomon, G., & Sills, A. (2019). Engaging athletic trainers in concussion detection: Overview of the National Football League ATC spotter program, 2011-2017. Journal of Athletic Training, 54(8), 852–857. Visit Source.
Makdissi, M., Critchley, M. L., Cantu, R. C., Caron, J. G., Davis, G. A., Echemendia, R. J., Fremont, P., Hayden, K. A., Herring, S. A., Hinds, S. R., Jordan, B., Kemp, S., McNamee, M., Maddocks, D., Nagahiro, S., Patricios, J., Putukian, M., Turner, M., Sick, S., & Schneider, K. J. (2023). When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review. British Journal of Sports Medicine, 57(12), 822–830. Visit Source.
Mallory, K. D., Saly, L., Hickling, A., Colquhoun, H., Kroshus, E., & Reed, N. (2022). Concussion education in the school setting: A scoping review. The Journal of School Health, 92(6), 605–618. Visit Source.
Master, C. L., Bacal, D., Grady, M. F., Hertle, R., Shah, A. S., Strominger, M., Whitecross, S., Bradford, G. E., Lum, F., & Donahue, S. P. (2022). Vision and concussion: Symptoms, signs, evaluation, and treatment. PEDIATRICS, 150(2). Visit Source.
Mavroudis, I., Ciobica, A., Luca, A. C., & Balmus, I. M. (2023). Post-traumatic headache: A review of prevalence, clinical features, risk factors, and treatment strategies. Journal of Clinical Medicine, 12(13), 4233. Visit Source.
May, T., Foris, L. A., & Donnally, C. J., III. (2023). Second impact syndrome. StatPearls - NCBI Bookshelf. Visit Source.
Mayo Clinic. (n.d.). Concussion - Symptoms and causes. Mayo Clinic. Visit Source.
McGuine, T. A., Pfaller, A. Y., Post, E. G., Hetzel, S. J., Brooks, A., & Broglio, S. P. (2018). The Influence of Athletic Trainers on the Incidence and Management of Concussions in High School Athletes. Journal of Athletic Training, 53(11), 1017–1024. Visit Source.
McKee, C. S., Bleakley, C., Rankin, A., & Matthews, M. (2024). Outcome measures used in adolescent sport-related concussion research: A scoping review. BMJ Open, 14(9), e075590. Visit Source.
McPherson, A. L., Nagai, T., Webster, K. E., & Hewett, T. E. (2019). Musculoskeletal injury risk after sport-related concussion: A systematic review and meta-analysis. The American Journal of Sports Medicine, 47(7), 1754–1762. Visit Source.
Mihalik, J. P., McCaffrey, M. A., Rivera, E. M., Pardini, J. E., Guskiewicz, K. M., Collins, M. W., & Lovell, M. R. (2007). Effectiveness of mouthguards in reducing neurocognitive deficits following sports-related cerebral concussion. Dental Traumatology: Official Publication of International Association for Dental Traumatology, 23(1), 14–20. Visit Source.
Miller, J. J., Hansen, K., Dorman, J., Jensen, K., Gurumoorthy, A., & Combs, J. (2025). Sports medicine physician confidence in concussion assessments for postconcussion return-to-play decisions. Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine, 35(3), 269–277. Visit Source.
Miller, S. M., Zynda, A. J., Sabatino, M. J., Ellis, H. B., Jr., & Dimeff, R. (2019). DOCOSAHEXAENOIC ACID (DHA) FOR THE TREATMENT OF PEDIATRIC SPORT-RELATED CONCUSSION: RESULTS OF A FEASIBILITY TRIAL. Orthopaedic Journal of Sports Medicine, 7(3 Suppl), 2325967119S00004. Visit Source.
Morrissey, S., Dumire, R., Causer, T., Colton, A., Oberlander, E., Frye, D., Shepherd-Porada, K., & Frye, L. (2019). The missing piece of the concussion discussion: Primary prevention of mild traumatic brain injury in student athletes. Journal Of Emergency and Critical Care Medicine, 3. Visit Source.
Mucha, A., Collins, M. W., Elbin, R., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., Marchetti, G., & Kontos, A. P. (2014). A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions. The American Journal of Sports Medicine, 42(10), 2479–2486. Visit Source.
Mucha, A., & Trbovich, A. (2019). Considerations for diagnosis and management of concussion. The Journal of Orthopaedic and Sports Physical Therapy, 49(11), 787–798. Visit Source.
Mucha, A. (2024). Physical Therapy Guide to Concussion. Choose PT. Visit Source.
Munakomi, S., & Puckett, Y. (2024). Chronic traumatic encephalopathy. In StatPearls. StatPearls Publishing. Visit Source.
Narad, M. E., Epstein, J. N., Peugh, J., Barber Foss, K. D., Diekfuss, J. A., Bonnette, S., Orban, S., Yuan, W., Dudley, J. A., DiCesare, C. A., Reddington, D. L., Zhong, W., Nissen, K. S., Shafer, J. L., Avedesian, J. M., Slutsky-Ganesh, A. B., Lloyd, R. S., Howell, D., & Myer, G. D. (2022). Effect of subconcussive head impact exposure and jugular vein compression on behavioral and cognitive outcomes after a single season of high-school football: A prospective longitudinal trial. Journal of Neurotrauma, 39(1-2), 49–57. Visit Source.
National Operating Committee on Standards for Athletic Equipment. (2018). Commissioning research and establishing standards for athletic equipment, where feasible, and encouraging dissemination of research findings on athletic equipment and sports injuries. Visit Source.
Olson, A., Ellis, M. J., Selci, E., & Russell, K. (2020). Delayed symptom onset following pediatric sport-related concussion. Frontiers in Neurology, 11, 220. Visit Source.
Obana, K. K., Mueller, J. D., Saltzman, B. M., Bottiglieri, T. S., Ahmad, C. S., Parisien, R. L., & Trofa, D. P. (2021). Targeting rule implementation decreases concussions in high school football: A National Concussion Surveillance Study. Orthopaedic Journal of Sports Medicine, 9(10), 23259671211031191. Visit Source.
Pandey, H. S., Lahijanian, B., Schmidt, J. D., Lynall, R. C., Broglio, S. P., McAllister, T. W., McCrea, M. A., Pasquina, P. F., Garcia, G. P., & CARE Consortium Investigators (2025). Quantifying the dagnostic utility of baseline testing in concussion management: An analysis of collegiate athletes from the NCAA-DoD CARE consortium dataset. The American Journal of Sports Medicine, 53(1), 181–191. Visit Source.
Patel, H., Polam, S., & Joseph, R. (2024). Concussions: A review of physiological changes and long-term sequelae. Cureus, 16(2), e54375. Visit Source.
Patricios, J. S., Schneider, K. J., Dvorak, J., Ahmed, O. H., Blauwet, C., Cantu, R. C., Davis, G. A., Echemendia, R. J., Makdissi, M., McNamee, M., Broglio, S., Emery, C. A., Feddermann-Demont, N., Fuller, G. W., Giza, C. C., Guskiewicz, K. M., Hainline, B., Iverson, G. L., Kutcher, J. S., Leddy, J. J., … Meeuwisse, W. (2023a). Consensus statement on concussion in sport: The 6th International Conference on Concussion in Sport-Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695–711. Visit Source.
Patricios, J., Schneider, G. M., Van Ierssel, J., Purcell, L. K., Davis, G. A., Echemendia, R. J., Frémont, P., Fuller, G. W., Herring, S., Harmon, K. G., Holte, K., Loosemore, M., Makdissi, M., McCrea, M., Meehan, W. P., O’Halloran, P., Premji, Z., Putukian, M., Shill, I. J., . . . Schneider, K. J. (2023b). Sport Concussion Office Assessment Tool 6 (SCOAT6). British Journal of Sports Medicine, 57(11), 651–667. Visit Source.
Pfaller, A. Y., Brooks, M. A., Hetzel, S., & McGuine, T. A. (2019). Effect of a new rule limiting full-contact practice on the incidence of sport-related concussion in high school football players. The American Journal of Sports Medicine, 47(10), 2294–2299. Visit Source.
Potteiger, K. L., Potteiger, A. J., Pitney, W, Wright, PM. (2018). An examination of concussion legislation in the United States. The Internet Journal of Allied Health Sciences and Practice. 16(2), Article 6. Visit Source.
Purcell, L. K., Davis, G. A., & Gioia, G. A. (2019). What factors must be considered in 'return to school' following concussion and what strategies or accommodations should be followed? A systematic review. British Journal of Sports Medicine, 53(4), 250. Visit Source.
Ramsay, S., & Dahinten, S. (2020). Concussion education in children and youth: A scoping review. SAGE Open Nursing, 6, 2377960820938498. Visit Source.
Rapp, G. C., & Ingersoll, C. D. (2019). Sports medicine delivery models: Legal risks. Journal of Athletic Training, 54(12), 1237–1240. Visit Source.
Renton, T., Petersen, B., & Kennedy, S. (2021). Investigating correlates of athletic identity and sport-related injury outcomes: A scoping review. BMJ Open, 11(4), e044199. Visit Source.
Rice, T., & Curtis, R. (2019). Parental knowledge of concussion: Evaluation of the CDC's "Heads up to parents" educational initiative. Journal of Safety Research, 69, 85–93. Visit Source.
Schmidt, J. D., Suggs, D. W., Rawlins, M. L. W., Bierema, L., Miller, L. S., Courson, R., & Reifsteck, F. (2020a). Coach, sports medicine, and parent influence on concussion care seeking intentions and behaviors in collegiate student athletes. Journal of Clinical and Translational Research, 5(4), 215–226. Visit Source.
Schmidt, J. D., Rawlins, M. L. W., Lynall, R. C., D'Lauro, C., Clugston, J. R., McAllister, T. W., McCrea, M., Broglio, S. P., & CARE Consortium Investigators (2020b). Medical disqualification following concussion in collegiate student-athletes: Findings from the CARE consortium. Sports Medicine, 50(10), 1843–1855. Visit Source.
Scorza, K. A., & Cole, W. (2019). Current concepts in concussion: Initial evaluation and management. American Family Physician, 99(7), 426–434. Visit Source.
Sidelined USA. (n.d.). About. Sideline USA. Visit Source.
Silverberg, N. D., Duhaime, A. C., & Iaccarino, M. A. (2020). Mild traumatic brain injury in 2019-2020. JAMA, 323(2), 177–178. Visit Source.
Silverman, S., Vidt, M. E., Hong, J. S., & Grafton, L. M. (2024). Risk reduction of concussion in athletes: Do neck size or neck strength make a difference? American Journal of Physical Medicine & Rehabilitation, 103(7), 659–664. Visit Source.
Trinh, L. N., Brown, S. M., & Mulcahey, M. K. (2020). The influence of psychological factors on the incidence and severity of sports-related concussions: A systematic review. The American Journal of Sports Medicine, 48(6), 1516–1525. Visit Source.
Wallace, J., Covassin, T., Nogle, S., Gould, D., & Kovan, J. (2017). Knowledge of concussion and reporting behaviors in high school athletes with or without access to an athletic trainer. Journal of Athletic Training, 52(3), 228–235. Visit Source.
Wang, E. X., Hwang, C. E., Nguyen, J. N., Segovia, N. A., Abrams, G. D., & Kussman, A. (2022). Factors associated with a prolonged time to return to play after a concussion. The American Journal of Sports Medicine, 50(6), 1695–1701. Visit Source.
Williamson, C. L., Norte, G. E., Broshek, D. K., Hart, J. M., & Resch, J. E. (2018). Return to learn after sport-related concussion: A survey of secondary school and collegiate athletic trainers. Journal of Athletic Training, 53(10), 990–1003. Visit Source.
Yuan, W., Diekfuss, J. A., Barber Foss, K. D., Dudley, J. A., Leach, J. L., Narad, M. E., DiCesare, C. A., Bonnette, S., Epstein, J. N., Logan, K., Altaye, M., & Myer, G. D. (2021). High school sports-related concussion and the effect of a jugular vein compression collar: A prospective longitudinal investigation of neuroimaging and neurofunctional outcomes. Journal of Neurotrauma, 38(20), 2811–2821. Visit Source.
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