Concussion-Related Decision-Making by Certified Athletic Trainers: Implications for Concussion Prevention and Care.

Concussions are a common sport-related injury that require appropriate initial care. Athletic trainers, often a primary source of healthcare for student-athletes, are key individuals involved in initial concussion diagnostic and management decisions. Challenges exist within the athletic environment that may hinder the consistency, efficacy, and/or effectiveness of concussion-related decision-making by athletic trainers, thereby impacting secondary concussion prevention and patient health. The purpose of this study was to identify factors that impact the intentions of athletic trainers to make appropriate concussion-related decisions under various circumstances. Overall, 1029 participants completed a survey examining educational precursors (quantity and quality of healthcare communication educational focus), demographic precursors (age, gender, educational degree, and employment setting), theory-based mediators (attitudes, perceived norms, and personal agency), and external mediators (knowledge, salience, and communication/collaboration practices) on appropriate concussion-related decision-making intentions. Data were analyzed using a two-step structural equation modeling approach. Quality of healthcare communication educational focus indirectly impacted appropriate concussion-related decision-making intentions via perceived behavioral control and communication/collaboration practices. Additionally, several factors impacted intentions to make appropriate concussion-related decisions directly including employment setting, self-efficacy, and general attitudes towards decision-making and concussions. Concussion prevention is aided by the initial and appropriate action taken by a healthcare professional to reduce immediate consequences; however, this action may be influenced by stakeholder relationships. These influential factors of decision-making may place athletes at further injury risk and negatively impact overall athlete health. As such, a sound theoretical framework incorporating the complexity of factors that may influence decision-making is needed.

Comparison of Concussion Sideline Screening Measures Across Varying Exertion Levels Within Simulated Games.

CONTEXT: Currently, there is no gold standard to evaluate the effect of varying game-like exertion states on Sport Concussion Assessment Tool 3rd Edition (SCAT-3) outcomes. Baseline assessments may occur before, during, or after physical activity, while postinjury evaluations predominantly occur following physical activity. Thus, clinicians may be comparing postinjury evaluations completed following exertion to baseline evaluations completed following varying levels of rest or exertion, which may not be a valid method for clinical decision making. OBJECTIVE: To determine the effect of various physical exertion levels on sideline concussion assessment outcomes and reliability. DESIGN: Within-subjects, repeated measures. SETTING: Field. PARTICIPANTS: Physically active participants (N = 36) who regularly participate in basketball activity. INTERVENTION: Subjects participated in 2 simulated basketball games, completing a symptom checklist, Standardized Assessment of Concussion, and Balance Error Scoring System before game play, during halftime, and at the completion of each simulated game. Pulse rate was assessed as a proxy of physical exertion. MAIN OUTCOME MEASURES: Total symptom, Standardized Assessment of Concussion, and Balance Error Scoring System scores. RESULTS: Physical exertion did not significantly predict symptom, Standardized Assessment of Concussion, or Balance Error Scoring System scores, although a trend toward higher symptom scores was observed for females (ß = 0.03, P = .09). All assessments had poor to moderate reliability across sessions (.15 < interclass correlation coefficient [2,1] < .60). CONCLUSION: Low- to moderate-intensity physical activity did not have a significant effect on clinical concussion sideline assessments; however, the low test-retest reliability observed prevents strong conclusions on these relationships. The poor overall reliability does not allow for clear recommendations for what state of baseline physical exertion (ie, rested or exerted) provides optimal data to make postinjury clinical decisions, although baseline concussion assessments completed at rest have the most valid and conservative normative values for injury comparison.

Delivering Chest Compressions and Ventilations With and Without Men's Lacrosse Equipment.

CONTEXT: Current management recommendations for equipment-laden athletes in sudden cardiac arrest regarding whether to remove protective sports equipment before delivering cardiopulmonary resuscitation are unclear. OBJECTIVE: To determine the effect of men's lacrosse equipment on chest compression and ventilation quality on patient simulators. DESIGN: Cross-sectional study. SETTING: Controlled laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-six licensed athletic trainers (18 women, 8 men; age = 25 ± 7 years; experience = 2.1 ± 1.6 years). INTERVENTION(S): In a single 2-hour session, participants were block randomized to 3 equipment conditions for compressions and 6 conditions for ventilations on human patient simulators. MAIN OUTCOME MEASURE(S): Data for chest compressions (mean compression depth, compression rate, percentage of correctly released compressions, and percentage of optimal compressions) and ventilations (ventilation rate, mean ventilation volume, and percentage of ventilations delivering optimal volume) were analyzed within participants across equipment conditions. RESULTS: Keeping the shoulder pads in place reduced mean compression depth (all P values < .001, effect size = 0.835) and lowered the percentages of both correctly released compressions ( P = .02, effect size = 0.579) and optimal-depth compressions (all P values < .003, effect size = 0.900). For both the bag-valve and pocket masks, keeping the chinstrap in place reduced mean ventilation volume (all P values < .001, effect size = 1.323) and lowered the percentage of optimal-volume ventilations (all P values < .006, effect size = 1.038). Regardless of equipment, using a bag-valve versus a pocket mask increased the ventilation rate (all P values < .003, effect size = 0.575), the percentage of optimal ventilations (all P values < .002, effect size = 0.671), and the mean volume ( P = .002, effect size = 0.598) across all equipment conditions. CONCLUSIONS: For a men's lacrosse athlete who requires cardiopulmonary resuscitation, the shoulder pads should be lifted or removed to deliver chest compressions. The facemask and chinstrap, or the entire helmet, should be removed to deliver ventilations, preferably with a bag-valve mask.

Head Impact Biomechanics in Women's College Soccer.

INTRODUCTION: There are limited nonlaboratory soccer head impact biomechanics data. This is surprising given soccer's global popularity. Epidemiological data suggest that female college soccer players are at a greater concussion injury risk than their male counterparts. Therefore, the purposes of our study were to quantify head impact frequency and magnitude during women's soccer practices and games in the National Collegiate Athletic Association and to characterize these data across event type, playing position, year on the team, and segment of game (first and second halves). METHODS: Head impact biomechanics were collected from female college soccer players (n = 22; mean ± SD age = 19.1 ± 0.1 yr, height = 168.0 ± 3.5 cm, mass = 63.7 ± 6.0 kg). We employed a helmetless head impact measurement device (X2 Biosystems xPatch) before each competition and practice across a single season. Peak linear and rotational accelerations were categorized based on impact magnitude and subsequently analyzed using appropriate nonparametric analyses. RESULTS: Overall, women's college soccer players experience approximately seven impacts per 90 min of game play. The overwhelming majority (~90%) of all head impacts were categorized into our mildest linear acceleration impact classification (10g-20g). Interestingly, a higher percentage of practice impacts in the 20g-40g range compared with games (11% vs 7%) was observed. CONCLUSION: Head impact biomechanics studies have provided valuable insights into understanding collision sports and for informing evidence-based rule and policy changes. These have included changing the football kickoff, ice hockey body checking ages, and head-to-head hits in both sports. Given soccer's global popularity, and the growing public concern for the potential long-term neurological implications of collision and contact sports, studying soccer has the potential to impact many athletes and the sports medicine professionals caring for them.

Helmet fit and cervical spine motion in collegiate men's lacrosse athletes secured to a spine board.

CONTEXT: Proper management of cervical spine injuries in men's lacrosse players depends in part upon the ability of the helmet to immobilize the head. OBJECTIVE: To determine if properly and improperly fitted lacrosse helmets provide adequate stabilization of the head in the spine-boarded athlete. DESIGN: Crossover study. SETTING: Sports medicine research laboratory. PATIENTS OR OTHER PARTICIPANTS: Eighteen healthy collegiate men's lacrosse players. INTERVENTION(S): Participants were asked to move their heads through 3 planes of motion after being secured to a spine board under 3 helmet conditions. MAIN OUTCOME MEASURE(S): Change in range of motion in the cervical spine was calculated for the sagittal, frontal, and transverse planes for both head-to-thorax and helmet-to-thorax range of motion in all 3 helmet conditions (properly fitted, improperly fitted, and no helmet). RESULTS: Head-to-thorax range of motion with the properly fitted and improperly fitted helmets was greater than in the no-helmet condition (P < .0001). In the sagittal plane, range of motion was greater with the improperly fitted helmet than with the properly fitted helmet. No difference was observed in helmet-to-thorax range of motion between properly and improperly fitted helmet conditions. Head-to-thorax range of motion was greater than helmet-to-thorax range of motion in all 3 planes (P < .0001). CONCLUSIONS: Cervical spine motion was minimized the most in the no-helmet condition, indicating that in lacrosse players, unlike football players, the helmet may need to be removed before stabilization.

Comparison of 3 Airway Access Techniques During Suspected Spine Injury Management in American Football.

OBJECTIVE: To determine how head movement and time to access airway were affected by 3 emergency airway access techniques used in American football. DESIGN: Prospective counterbalanced design. SETTING: University research laboratory. PARTICIPANTS: Eighteen certified athletic trainers (ATCs) and 18 noncertified students (NCSs). INTERVENTIONS: Each participant performed 1 trial of each of the 3 after airway access techniques: quick release mechanism (QRM), cordless screwdriver (CSD), and pocket mask insertion (PMI). MAIN OUTCOME MEASURES: Time to task completion in seconds, head movement in each plane (sagittal, frontal, and transverse), maximum head movement in each plane, helmet movement in each plane, and maximum helmet movement in each plane. RESULTS: We observed a significant difference between all 3 techniques with respect to time required to achieve airway access (F2,68 = 263.88; P < 0.001). The PMI allowed for the quickest access followed by the QRM and CSD techniques, respectively. The PMI technique also resulted in significantly less head movement (F2,68 = 9.06; P = 0.001) and less maximum head movement (F2,68 = 13.84; P < 0.001) in the frontal plane compared with the QRM and CSD techniques. CONCLUSIONS: The PMI technique should be used to gain rapid airway access when managing a football athlete experiencing respiratory arrest in the presence of a suspected cervical spine injury. In the event the athlete does not present with respiratory arrest, the facemask may be removed carefully with a pocket mask ready. Medical professionals must be familiar with differences in equipment and the effects these may have on the management of the spine-injured athlete.

Comparison of 3 airway access techniques during suspected spine injury management in American football.

OBJECTIVE: To determine how head movement and time to access airway were affected by 3 emergency airway access techniques used in American football. DESIGN: Prospective counterbalanced design. SETTING: University research laboratory. PARTICIPANTS: Eighteen certified athletic trainers (ATCs) and 18 noncertified students (NCSs). INTERVENTIONS: Each participant performed 1 trial of each of the 3 after airway access techniques: quick release mechanism (QRM), cordless screwdriver (CSD), and pocket mask insertion (PMI). MAIN OUTCOME MEASURES: Time to task completion in seconds, head movement in each plane (sagittal, frontal, and transverse), maximum head movement in each plane, helmet movement in each plane, and maximum helmet movement in each plane. RESULTS: We observed a significant difference between all 3 techniques with respect to time required to achieve airway access (F(2,68) = 263.88; P < 0.001). The PMI allowed for the quickest access followed by the QRM and CSD techniques, respectively. The PMI technique also resulted in significantly less head movement (F(2,68) = 9.06; P = 0.001) and less maximum head movement (F(2,68) = 13.84; P < 0.001) in the frontal plane compared with the QRM and CSD techniques. CONCLUSIONS: The PMI technique should be used to gain rapid airway access when managing a football athlete experiencing respiratory arrest in the presence of a suspected cervical spine injury. In the event the athlete does not present with respiratory arrest, the facemask may be removed carefully with a pocket mask ready. Medical professionals must be familiar with differences in equipment and the effects these may have on the management of the spine-injured athlete.

Effect of ice hockey helmet fit on cervical spine motion during an emergency log roll procedure.

OBJECTIVE: To investigate cervical spine motion during a log roll technique in ice hockey players under different helmet fit conditions. DESIGN: Prospective counterbalanced design. SETTING: University research laboratory. PARTICIPANTS: Eighteen club ice hockey players were recruited to participate in this study. ASSESSMENT OF RISK FACTORS: A standard emergency log roll was performed 3 times under each of 3 different helmet fit conditions: properly fit, improperly (competition) fit, and helmet-removed. MAIN OUTCOME MEASUREMENTS: Frontal, sagittal, and transverse plane cervical spine motion were used as outcome measures. RESULTS: Significantly less sagittal and transverse plane motion occurred during the helmet-removed condition. No differences in frontal plane motion among the 3 conditions were observed. CONCLUSIONS: Presence of helmet (whether properly fit or not) resulted in increased of sagittal and transverse plane movement. This suggests that when an ice hockey helmet is stabilized, the head within it is not. We recommend the helmet and face shield be removed before performing an emergency prone log roll.