SPORTS-RELATED CONCUSSION TESTING AS UTILIZED BY CERTIFIED
ATHLETIC TRAINERS IN NATA DISTRICT 2

A THESIS
Submitted to the Faculty of the School of Graduate Studies and
Research
of
California University of Pennsylvania in partial fulfillment of
the requirements for the degree of
Master of Science

by
Bethany J. Arbaugh

Research Advisor, Dr. Carol Biddington
California, Pennsylvania
2010

ii

iii
ACKNOWLEDGEMENTS

I would like to thank all of the people who have
helped and inspired me during my study.

My deepest

gratitude goes to the most important people in my life: my
mother and father; my sisters, Gwendolyn and Carlie; my
grandmother; and especially my fiancé, Ryan.

Mom and dad,

you both have always been there for me, supporting me in
every way possible and continuing to encourage me through
my goals and dreams.

Gwendolyn and Carlie, thank you for

being there for me through my youth and helping me grow as
a sister, a friend, and a person.

I could not ask for more

understanding and loving sisters.

Grandmom, thank you for

always being there for me when I need someone to talk to,
showing me how to grow spiritually with God, and sending me
all of those encouraging letters during my years away from
home.

Ryan, you have always been there with me through the

good times and the bad.

You are the one person I can count

on in my life to always be there for me and let me know
that everything is going to be okay.

You are the most

loving and kindest person I know, and I would not be where
I am today without you.

You will forever be my best

friend, my other half, and I will love you always.

iv
I would also like to thank all my peers and friends
from home, Lynchburg, and Cal U.

The constant support that

I received from each of you means the world to me and I am
lucky to have known you.
I want to say a special thanks my thesis chairperson,
Dr. Carol Biddington, and other thesis committee members,
Dr. Joni Roh and Dr. Jamie Weary.

Carol, your support and

drive to push me through this challenging time in my life
as well as your motivation to advise me in whatever I need
has been phenomenal.

In addition, you were always

accessible and willing to help me with my research and any
questions that I had during my study.

Joni and Jamie, your

perpetual energy and enthusiasm in research has motivated
me to make my study the best that it can be.

As a result,

research life here at Cal U has been smooth and rewarding.
Thank you for everything.
Finally yet importantly, thanks to God for my life
through all the challenges and tests in the past years.
You have made my life more beautiful, showing me what is
most important, staying healthy and happy.
be exalted, honored, and glorified.

May your name

v

TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS .
LIST OF TABLES

. . . . . . . . . . . . . . . viii

LIST OF FIGURES .
INTRODUCTION .
METHODS .

. . . . . . . . . . . . . v

. . . . . . . . . . . . . . x

. . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . 11

Research Design. . . . . . . . . . . . . . 11
Subjects .

. . . . . . . . . . . . . . . 12

Instruments .

. . . . . . . . . . . . . . 13

Procedures. . . . . . . . . . . . . . . . 13
Hypothesis. . . . . . . . . . . . . . . . 14
Data Analysis. . . . . . . . . . . . . . . 15
RESULTS .

. . . . . . . . . . . . . . . . . 16

Demographic Data .

. . . . . . . . . . . . 16

Hypothesis Testing

. . . . . . . . . . . . 23

Additional Findings . . . . . . . . . . . . 24
DISCUSSION .

. . . . . . . . . . . . . . . . 36

Discussion of Results . . . . . . . . . . . 36
Conclusions .

. . . . . . . . . . . . . . 43

Recommendations. . . . . . . . . . . . . . 44
REFERENCES .

. . . . . . . . . . . . . . . . 46

vi
APPENDICES .

. . . . . . . . . . . . . . . . 49

APPENDIX A: Review of Literature .

. . . . . . . 50

Sports-Related Concussion. . . . .

. . . . . . . 52

Definition of Concussion . . . . . . . . . . 53
Sideline Evaluation.
Management Guidelines.

. . . . . . . . . . . 55
. . . . . . . . . . 56

Return-to-Play. . . . . . . . . . . . . . . 59
When to Refer.

. . . . . . . . . . . . . . 62

Concussions in Athletes.

. . . . . . . . . . . 64

Contact Sports and Concussions.

. . . . . . 65

High School vs. Collegiate L evel Sports.

. . 66

Concussion Assessment and Diagnostic Tools .
Sideline Assessment Testing.

. 69

. . . . . . . . . 70

Concussion Grading Scales. . . . . . . . . . . 71
Cantu Guidelines . . . . . . . . . . . . . 71
Colorado Medical Society Guidelines. . . . . . 72
American Academy of Neurology Guidelines. . . . 73
Pencil and Paper Assessment Testing

. . . . . . 74

Standardized A ssessment of Concussion(SAC). 74
Balance Error Scoring System(BESS) . . . . 77
Computer Based Concussion Testing. . . . . . 79
CogSport.

. . . . . . . . . . . . . . . 80

HeadMinder C RI. . . . . . . . . . . . . . 81
ImPACT.

. . . . . . . . . . . . . . . . 84

vii
Summary .

. . . . . . . . . . . . . . . . . 88

APPENDIX B: The Problem . . . . . . . . . . . . 91
Statement of the Problem

. . . . . . . . . . . 92

Definition of Terms

. . . . . . . . . . . . . 93

Basic Assumptions .

. . . . . . . . . . . . . 94

Limitations of the Study

. . . . . . . . . . . 94

Significance of the Study .

. . . . . . . . . . 95

APPENDIX C: Additional Methods .

. . . . . . . . 97

Concussion Grading System Scales(C1).

. . . . . . 98

Concussion Testing as Utilized and Preferred by
Certified Athletic Trainers Survey (C2). . . . . . 101
Institutional Review Board (C3) . . . . . . . . . 106
Subject Cover Letter (C4) . . . . . . . . . . . 108
REFERENCES . . . . . . . . . . . . . . . . . 111
ABSTRACT

. . . . . . . . . . . . . . . . . 116

viii

LIST OF TABLES

Tables

Page

1. Gender of ATs . . . . . . . . . . . . . . . 14
2. ATs Highest Educational Level . . . . . . . . . 14
3. State Currently Practicing as ATs. . . . . . . . 15
4. Additional Professional Credentials
5. Years Working as an ATC
6. ATs Primary Position
7. ATs Employment Setting

. . . . . . 15

. . . . . . . . . . 16

. . . . . . . . . . . . 16
. . . . . . . . . . . 17

8. Current Concussion Assessment Method . . . . . . 17
9. Concussion Assessment Methods . . . . . . . . . 18
10. Concussion Assessment Method Decision Making

. . 18

11. Responsibility for Concussion Assessment Method
Decision Making . . . . . . . . . . . . . . 19
12. Concussion Assessment Method Utilized by ATs

. . 19

13. Concussion Assessment Method Preferred by ATs . . 19
14. Method of Influence on ATs

. . . . . . . . . 20

15. Chi-Square Goodness of Fit for Currently Used
Concussion Assessment Method . . . . . . . . . 21
16. Chi-Square Goodness of Fit for ATs Highest
Educational Level . . . . . . . . . . . . . . 22

ix
17. Chi-Square Goodness of Fit for State Currently
Practicing . . . . . . . . . . . . . . . . 24
18. Chi-Square Goodness of Fit for Concussion
Assessment Method Decision Making

. . . . . . . 25

19. Chi-Square Goodness of Fit for Concussion
Assessment Method Utilized by ATs . . . . . . . 26
20. Chi-Square Goodnes of Fit for Concussion
Assessment Method Preferred by ATs . . . . . . 26
21. Chi-Square Goodness of Fit for Method of
Influence on ATs . . . . . . . . . . . . . . 27
22. 2x2 Chi-Square Independence Test for Gender /
Concussion Assessment Method Decision Making . . 29
23. 4x3 Chi-Square Independence Test for State
Currently

Practicing / Concussion Assessment

Method Utilized . . . . . . . . . . . . . . 29
24. 4x3 Chi-Square Independence Test for State
Currently Practicing / Concussion Assessment
Method Preferred . . . . . . . . . . . . . . 30

x

LIST OF FIGURES

Figures

Page

1. Bar Chart showing which concussion assessment
method is

currently being utilized at institution/

job site . . . . . . . . . . . . . . . . . 21
2. Bar chart showing highest level of education
obtained by ATs

. . . . . . . . . . . . . . 23

3. Pie chart showing which state the ATs are currently
Practicing .

. . . . . . . . . . . . . . . 24

4. Bar chart showing if AT is responsible for making
decisions about what concussion assessment method is
utilized . . . . . . . . . . . . . . . . . 25
5. Bar chart comparing results utilized concussion
assessment method by ATs and preferred concussion
assessment method by ATs . . . . . . . . . . . 27
6. Bar chart showing method of influence on ATs to
utilize concussion assessment method of choice . . 28
7. Bar chart comparing means between utilized
concussion assessment methods and preferred
concussion assessment method for ATs years of
certification . . . . . . . . . . . . . . . 31

1

INTRODUCTION
Sports-related concussions are a major sports medicine
issue in the current medical literature as well as popular
media of today because of post-concussion syndrome (PCS)
and second impact syndrome (SIS).

There have been many

guidelines constructed to allow for better identification,
assessment, diagnosis, and management of return to play for
athletes sustaining this serious injury.

The tools used to

better diagnose and assess sports-related concussions range
from standard balance screening to computerized
neurological testing, but there is still no gold standard
of which is more suited for healthcare providers.

The

Center for Disease Control and Prevention (CDC) has revised
educational materials for healthcare providers treating
concussions and mild traumatic brain injuries (MTBI).

As

part of the revision of the CDC they have updated the
definition of concussion to reflect current medical
opinion.1

The CDC defines concussion or mild traumatic

brain injury (MTBI) as the following:
“The term mild traumatic brain injury (MTBI) is used
interchangeably with the term concussion. This is defined
as a complex pathophysiologic process affecting the brain,

2
induced by traumatic biochemical forces secondary to direct
or indirect forces to the head. MTBI is caused by a blow or
jolt to the head that disrupts the function of the brain.
This disturbance of brain function is typically associated
with normal structural neuroimaging findings (i.e., CT
scan, MRI)”.1(p.2)
Sports-related concussions also known as mild
traumatic brain injury in athletics is a major sports
medicine issue. Reports have shown concussion injuries in
multiple sports and the trend of this traumatic brain
injury has been increasing in occurrence over the past
several years.2 There has been great attention given to the
research of this injury to form a better understanding in
terms of athletes’ health concerns.

Still, many concerns

remain in relation to the assessment and management of
sports-related concussions.
The sideline examination is an important part of
concussion management for the role of the healthcare
provider.

There have been a number of sideline assessment

tools designed to help accurately assess and evaluate
sports-related concussions.3

A high-quality past medical

history and injury history should be taken with each
concussion.

Additionally, the health care provider should

also assess orientation, immediate memory, delayed recall,

3
concentration, and attention which are very important
factors when evaluating a concussion.3,4 Moreover, sportsrelated concussion assessments should include testing for
postural stability, cognitive function, and self-reported
symptoms.5

Some examples of these cerebral concussion

screening instruments include sideline evaluations such as:
concussion grading systems like the grading scales of
Cantu,6 Colorado Medical Society,7 and American Academy of
Neurology,8 as well as the pencil and paper assessment tests
like that of the Standard Assessment of Concussion (SAC),9
and the Balance Error Score System (BESS)10 for mild
traumatic brain injuries (MTBI).
Concussion grading systems are sets of criteria used
in the sports medicine world to determine the severity
(grade) of a sports-related concussion.11

There are at

least 16 different grading systems that exist, most which
are out-dated and not as effective as the current
assessment methods used by healthcare providers today.
Several of these grading scales use loss of consciousness
and amnesia as the primary determinates of the severity of
the injury.12

Three grading systems are among the more

commonly known assessment methods are the following: 1)
Cantu’s guidelines (1986) which were updated in 2001, 2)
Colorado Medical Society guidelines (1991), and 3) American

4
Academy of Neurology guidelines (1997).11

An example of

the grading scale used can be found in Appendix C1.13(p.884)
Computer-based concussion assessment tools, such as
ImPACT, CogSport, and Headminder CRI have gained popularity
in the sports medicine world over the last decade due to
complications following concussions in athletics, such as
SIS and PCS.

All of these neurocognative tools assist the

healthcare provider in evaluating and documenting memory,
brain processing speed, reaction time, and postconcussive
symptoms (PCS).

The results of these tests should be

interpreted in light of all the other factors pertaining to
the injury, which may include physical exam, age, gender,
and previous concussion history to help in return-to-play
decision making.

The more recently created computer based

assessment tools have been found through research to be the
most helpful and more effective in making critical return
to play decisions.14
Most of the concussion injuries sustained by athletes
involve relatively mild symptoms, and with the ability to
use computerized tests, the factor of baseline testing of
athletes has shown to be a very powerful assessment tool.
When there is the ability to compare pre- and postconcussion neuropsychological data, there is also the
ability to differentiate changes in the neurocognitive

5
status of an athlete with a sports-related concussion.14

In

addition, the healthcare provider is able to evaluate the
degree of symptom resolution in the athlete.

Computer-

based assessment testing along with accurate timing of
evaluation, may be the best suited tool to identify
neurocognitive deficits, progress towards full recovery,
and provide helpful assistance in return to play
decisions.14,15

Tests like ImPACT, CogSport, and HeadMinder

CRI all provide most of these tactics within each
assessment test.
The most challenging portion of the care for a
concussion injury is making the return-to-play decision
following this injury.3,4

There can be a lot of external

pressure from individuals such as coaches, parents, and the
patient to return the athlete to competition early.16
Preventing athletes from returning to their sport for
unnecessarily long periods of time may also have a
significant impact on the athlete’s career, financial
viability, and psychological functioning.17

However, there

is still a great importance in return-to-play decisions, a
premature decision making puts the athletes’ health at
risk.18
Research on the topic of sport-related concussions has
provided the athletic training profession, as well as other

6
medical professions, with valuable new knowledge over the
last decade.

The key to reducing the incidences and

severity of these injuries, in addition to improving
return-to-play decisions, is found in connecting the gap
between research and clinical practices.

The National

Athletic Trainers’ Association (NATA) has written a
position statement about the management of sport-related
concussion injuries, which provides information and
recommendations for certified athletic trainers,
physicians, and other health care providers who care for
athletes in all levels of sports.

These recommendations

are derived from the most recent scientific and clinic
based literature on sport-related concussions.

The

position statement is organized into several sections
including: 1)defining and recognizing concussions,
2)evaluating and making return-to-play decision,
3)concussion assessment tools, 4)when to refer an athlete
to a physician after concussion, 5)when to disqualify an
athlete, 6)special considerations for the young athlete,
7)home care, and 8)equipment issues.18
In the section of Evaluating and Making the Return-toPlay Decisions, the NATA recommends the athletic trainers
and team physician work together and agree on a philosophy
for managing sport-related concussion injuries before the

7
start of the athletic season.

Today, there are currently

three approaches commonly used which include: 1) grading
the concussion at the time of the injury, 2) deferring
final grading until all symptoms have resolved, or 3) not
using a grading scale but rather focusing attention on the
athlete’s recovery via symptoms, neurocognitive testing,
and postural-stability testing.18

Because there is such a

high occurrence of SIS, it is important that ATs and other
healthcare providers use the third approach recommended by
the NATA and supported by the literature.

Therefore, it is

the intent of the NATA to get all health care professionals
who work with athletes to focus attention on the athlete’s
recovery based on the athlete’s symptoms, neurocognitive
testing and postural-stability.18

Another recommendation is

that in addition to thorough clinical evaluation, formal
cognitive and postural-stability testing should be done to
assist in objectively determining injury severity and
readiness to return-to-play.18,19

It is suggested that no

test should be solely used to determine recovery or returnto-play for this injury presents itself in many different
ways.

The suggestion for return to play decisions should

be made after an incremental increase in activity followed
by sport-specific activities that do not place the athlete
at risk for additional concussions.

This should all be

8
accomplished before the athlete is released into full
participation as long as no recurrent signs or symptoms are
present during this time and the process should all be
agreed upon by all health care professionals involved with
the athlete.18
In the Concussion Assessment Tools section of the NATA
position statement, it is suggested that the use of
objective concussion assessment tools will help athletic
trainers more accurately identify deficits caused by injury
and post-injury recovery.

It is also recommended to

protect the athletes from potential risks associated with
prematurely returning to participation, potentially
exposing them to another concussion.

The concussion

assessment tool should include the following: 1)
combination of tests for cognition, 2) postural stability,
and 3) self-reported symptoms.

There are a combination of

brief screening tools appropriate for use on the sport
sidelines such as the SAC and BESS as well as more
extensive measures like neuropsychological testing and
computer based testing (ImPACT, CogSport, and Headminder
CRI) to more precisely evaluate recovery after the injury
has been sustained by the athlete.

The NATA recommends

that all evaluators be appropriately trained in the
standardized instructions for test administration and

9
scoring before using any instrument for clinical purposes.18
As with all clinical instruments used in healthcare, the
results from assessment measures to evaluate these injuries
should be integrated with all aspects of the injury
evaluation to ensure the most effective approach to
management and return-to-play decision making.18,19

The

position statement states that decisions about an athlete’s
return-to-play should never be based solely on the use of
one concussion testing method.18
The assessment tools available to all healthcare
providers, whether it paper and pencil or computer-based
tests, should be used to evaluate each domain of the
injury.

These tests provide the highest sensitivity and

specificity of concussion assessments and it also gives the
healthcare provider the most information to make an
informed decision for return-to-play.20

Throughout the

evaluation process the healthcare providers administering
the assessment should be aware about the development,
presence, intensity, and return of concussion related
symptoms.3,4,11

Under no circumstances should an athlete

return to play if he or she reports a symptom that is
categorized under a concussion.11,21 Management of and return
to participation following a sports-related concussion
should involve a team approach.

This includes educating

10
the athletes, parents, and coaches about the injury as well
as collaboration with all other medical personnel involved
in the injury.21
This study will attempt to answer the following
question:

1) As per the NATA Position Statement, is there a

preference for one of the methods currently being used to
assess sport-related concussions?

11

METHODS

The main purpose of this study is to determine the
common concussion assessment method used by certified
Athletic Trainers (ATs) for sports-related concussions
sustained by athletes.

Through a survey, the different

assessment tools and management guidelines used by ATs was
determined for injury diagnosis as well as return to play
decision making.

These findings will help in determining

the most common and effective way for concussion assessment
testing and management of the injury based on the NATA’s
position statement of recommended approaches for concussion
assessment.

The methods section describes how this

research was carried out and includes the following:
research design, subjects, instruments, procedures,
hypothesis, and data analysis.

Research Design

A descriptive research design was used by the
researcher to conduct the study.

The data was collected

using an online server, Survey Monkey.

The dependent

variable was the concussion testing methods for assessment:

12
1) grading scale, 2) pencil and paper, and 3) computerbased neurocognitive testing.

This survey will help

determine whether ATs are assessing sports-related
concussion based on the recommendations stated in the NATA
position statement.

Subjects

The subjects used in this research study included a
random sample of ATs (N = 152) from District 2 of the NATA
which includes: Pennsylvania, Delaware, New Jersey, and New
York.

The reasons the researcher chose to survey District

2 members are the following:
1)

California University of Pennsylvania is located in

District 2.
2)

Much of the research regarding computer-based

assessments originated in Pennsylvania which is also in
District 2.
Informed consent is implied when the subjects complete
and return the survey to the researcher.

13
Instruments

The researcher created the Sports-related Concussion
Testing as Utilized and Preferred by Certified Athletic
Trainers Survey (Appendix C2) with demographics, which
included the following: gender, years of experience as a
certified athletic trainer, credentials, current
occupation, and the level of education.

Additional items

related to assessment and return-to-play decision making of
sports-related concussion injuries were addressed (Question
8 - Question 14).

Procedures

The Institutional Review Board of California
University of Pennsylvania reviewed the study before it was
sent to any participants.

After approval from the IRB

(Appendix C3) the researcher requested a contact list from
the NATA Research and Graduate Study Department.

In this

form the district of interest was specified, a cover letter
(Appendix C4) was sent, including a link to Survey Monkey
for the questions to the survey.

The form was then sent to

the District 2 Secretary for processing.

After approval

from the District Secretary, the NATA sent the survey to a

14
random number of participants within District 2.

A random

sample of 152 members received the survey, electronically,
via an e-mail cover letter, which was written by the
researcher introducing herself to the sample and explaining
the purpose of the study.

The survey was designed to be

completed in 20 minutes or less.

The subjects then

completed the survey over the internet and gave their
consent by returning the survey anonymously.

Hypothesis

The following hypothesis was examined in this research
study:
1)

As per the NATA Position Statement, there will be a

preference for one of the methods currently being used to
assess sport-related concussions.

Data Analysis

The data was analyzed using SPSS version 17.0 with a
significance level of 0.05.
H1: A chi-square analysis was completed to determine
whether a majority of ATs in District 2 had a preference

15
for one of the methods currently being used to assess
sport-related concussions.

16

RESULTS

Demographic Data

NATA District 2 ATs (N = 152) voluntarily participated
in this study.
District 2.

Table 1 represents gender of ATs in

A relatively equal number females (51%) and

males (48%) were representative of the sample.
Table 1. Gender of ATs
Characteristic
Female
Male

Frequency
78
74

Percent
50.6
48.7

Table 2 represents the classifications of ATs highest
educational level.

A majority of the ATs surveyed have

completed their master’s degree (55.8%), followed by a
bachelor’s (36.4%), and finally a doctorate (5.8%).
Table 2. ATs Highest Educational Level
Classification
Frequency
Master’s degree
86
Bachelor’s degree
56
Doctoral degree
9

Percent
55.8
36.4
5.8

Table 3 represents the state in which the ATs are
currently practicing.

The majority of ATs were currently

practicing in the state of Pennsylvania (50.6%), followed

17
by New York (22.1%), followed by New Jersey (15.6%), and
then Delaware (4.5%).

Other states included were

California, Ohio, Nevada, Maryland, Hawaii, and
Massachusetts.
Table 3. State Currently Practicing as ATs
Classification
Frequency
Pennsylvania
78
New York
34
New Jersey
24
Delaware
7
Other
8

Percent
50.6
22.1
15.6
4.5
1.3

Of the ATs surveyed a little over a third of the ATs
did not have additional professional credentials (38.3%),
followed by teacher certification (18.8%).

Other

professional credentials (14.6%) that ATs possess include
SCS, personal trainer, nutrition specialist, MS, SES, NCSFCPT, CMT, ROT, LAT, NSCA-CPT, CES, DPT, MEd, Speed and
Explosion specialist, LMT, Registered Athletic
Administrator, and CKTP.

ATs with PES credentials (13.6%)

were close, followed by CSCS (12.3%), followed by EMT
(8.4%), and lastly PT (3.2%).
Table 4. Additional Professional Credentials
Classification
Frequency
None
59
Teacher Certification
29
Other
23
PES
21
CSCS
19
EMT
13
PT
5

Percent
38.3
18.8
14.6
13.6
12.3
8.4
3.2

18

Table 5 represents the years the participants have
been working as an AT.

On average, the sample of ATs have

worked 13.37 years ± 11.087 years.
Table 5. Years Working as an AT
Classification
Min.
Max.
Years
0
40

Mean
13.37

SD
11.087

Table 6 represents the primary position of the ATs.

A

little over half (55.8%) of the ATs surveyed state their
primary position as clinical.

Other primary positions

include high school outreach, secondary outreach,
unemployed, teaching assistant, and athletic trainer
substitute.
Table 6. ATs Primary Position
Classification
Frequency
Clinical
86
Other
36
Academic
18
Administrative
5
Student
5
Research
1

Percent
55.8
23.4
11.7
3.2
3.2
.6

Table 7 represents the current employment setting of
the ATs in District 2.

A majority of the ATs work in a

High School setting (50%) followed by the
College/University setting (29.9%).

Other employment

settings of ATs include physical therapy clinic, orthopedic

19
office, pediatric orthopedics department, unemployed,
general therapy clinic, and rehabilitation clinic.
Table 7. ATs Employment Setting
Classification
Frequency
High School
77
College/University
46
Other
14
Sports Medicine Clinic
8
Professional athletics
4
General Hospital setting
1
Academic department
1
Corporate health (company)
1

Percent
50.0
29.9
9.1
5.2
2.6
.6
.6
.6

Table 8 represents the method currently being used by
the ATs at their institution/job site based on the NATA
Concussion Position Statement.

Over three-fourths of the

ATs surveyed in PA do not use a grading system, but use
symptoms, neurocognitive testing, and postural stability
testing which is supporting the NATA position statement.
Approximately 18% of ATs in District 2 need to change their
approach to concussion assessment according to the NATA
position statement.

20
Table 8. Current Concussion Assessment Method
Classification
Frequency
Percent
No grading, but using
121
78.6
symptoms,
neurocognitive
testing
and postural
stability testing
Grading the concussion
19
12.3
Deferring final grading
8
5.2
until all s/s have
resolved

Table 9 represents the following concussion assessment
methods used by ATs during their career.

The most common

method used for concussion assessment is the ImPACT
(53.2%), followed by SAC (35.7%), then BESS (2.6%) and
HeadMinder CTI (1.3%).
Table 9. Concussion Assessment Methods
Classification
Frequency
ImPACT
82
SAC
55
BESS
4
HeadMinder CRI
2

Percent
53.2
35.7
2.6
1.3

Table 10 represents whether the ATs are the person
responsible for making decisions about what concussion
method to use.

The majority of the ATs surveyed are

responsible for making the decision as to what concussion
assessment method should be used in their job setting
(59.1%).

21
Table 10. Concussion Assessment Method Decision Making
Classification
Frequency
Percent
Yes
91
59.1
No
55
35.7

Table 11 represents the person who is responsible for
the decision making of which concussion assessment method
to utilize.

The ATs surveyed state that the majority of

concussion assessment method decision making is based on
the athletic trainer (22.7%), followed by the Team MD
(18.8%).

Other includes program coordinator, sports

medicine director, director of concussion clinic (PMR),
clinical manager, athletic training supervisor, joint
effort among all AT staff, league, both team MD and Head
Athletic Trainer, ER doctor referral, clinical director,
athlete’s physician, and parents have the option of using
ImPACT.
Table 11. Responsibility
Decision Making
Classification
Athletic Trainer
Team MD
Other
Athletic Director

for Concussion Assessment Method
Frequency
35
29
22
3

Percent
22.7
18.8
14.3
1.9

Table 12 represents the primary method typically used
by the ATs for concussion assessment.

The majority of the

ATs surveyed in District 2 use computer-based

22
neurocognitive testing (45.5%), followed by pencil and
paper (27.9%), and grading scale (21.4%).
Table 12. Concussion Assessment Method Utilized by ATs
Classification
Frequency
Percent
Computer-based Neuro70
45.5
cognitive testing
Pencil and Paper
43
27.9
Grading Scale
33
21.4

Table 13 represents the method the ATs prefer to use
when assessing concussion injuries.

The majority of ATs

surveyed prefer computer-based neurocognitive testing
(65.6%), followed by grading scale (13%) and pencil and
paper methods (13%).
Table 13. Concussion Assessment Method Preferred by ATs
Preference
Frequency
Percent
Computer-based Neuro101
65.6
cognitive testing
Grading Scale
20
13.0
Pencil and Paper
20
13.0

Table 14 represents how the concussion assessment
method used by ATs influenced them to use that method.
Both experience (36.4%) and supported research (35.1%) is
what influenced ATs to use the concussion assessment method
of they are currently using.
Table 14. Method of Influence on ATs
Classification
Frequency
Experience
56
Supported Research
54
Cost
22

Percent
36.4
35.1
14.3

23

Hypothesis Testing

The hypothesis was tested at an alpha level of 0.05.
Hypothesis 1: A chi-squared goodness of fit was used to
determine utilization of concussion assessment methods.
Significant deviation from the hypothesized values was
found (χ22 = 157.392, p < .001).
Conclusion: The most used concussion assessment method was
“No grading, but using symptoms, neurocognitive testing and
postural stability testing” among the ATs in District 2 of
the NATA (Table 15 and Figure 1).
Table 15. Chi-Square Goodness of Fit for Currently Used
Concussion Assessment Method
Type
n
χ2
p value
No grading, but using
symptoms,
neurocognitive
testing
and postural
stability testing
Grading the concussion
Deferring final grading
until all s/s have
resolved

121

19
8

157.392

<.001

24
Figure 1. Bar Chart showing which concussion assessment
method is currently being utilized at institution/job site.

Additional Findings

In addition to hypothesis testing, a chi-square
goodness of fit was calculated comparing the frequency of
occurrence of each of the following values.
A chi-square goodness of fit was used to determine the
frequency of occurrence among educational levels of ATs.
Significant deviation from the hypothesized values was

25
found among the classifications of ATs Highest Educational
Level (χ22 = 59.854, p < .001).

Most ATs have obtained a

Master’s Degree as their highest level of educational which
is significantly more than ATs with either a Bachelor’s or
Doctorate degree (Table 16 and Figure 2).
Table 16. Chi-Square Goodness of Fit for ATs Highest
Educational Level
Type
n
χ2
p value
Master’s Degree
86
59.854
<.001
Bachelor’s Degree
56
Doctoral Degree
9

26
Figure 2. Bar chart showing highest level of education
obtained by ATs.

A chi-square goodness of fit was used to determine
what state ATs are currently practicing in.

Significant

deviation from the hypothesized values was found among the
classifications of State Currently Practicing (χ23 =
111.550, p < .001).

Other states included are California,

Ohio, Nevada, Maryland, Hawaii, and Massachusetts.

Most

ATs are currently practicing in the state of Pennsylvania
(Table 17 and Figure 3).

27

Table 17. Chi-Square Goodness of Fit for State Currently
Practicing
Type
n
χ2
p value
Pennsylvania
78
111.550
<.001
New York
34
New Jersey
24
Other
8
Delaware
7

Figure 3. Pie chart showing which state the ATs are
currently practicing.

A chi-square goodness of fit was used to determine ATs
responsibility for concussion assessment method decision
making.

Significant deviation from the hypothesized values

was found among the classifications of Concussion
Assessment Method Decision Making (χ22 = 8.877, p < .01).
Most ATs are responsible for making decisions based on

28
which concussion assessment method is utilized (Table 18
and Figure 4).
Table 18. Chi-Square Goodness of Fit for Concussion
Assessment Method Decision Making
Type
n
χ2
p value
Yes
91
8.877
.003
No
55
Figure 4. Bar chart showing if AT is responsible for making
decisions about what concussion assessment method is
utilized.

A chi-square goodness of fit was used to determine
concussion assessment methods utilized by ATs.

Significant

deviation from the hypothesized values was found among the
classifications of Concussion Assessment Method Utilized by

29
ATs (χ22 = 15.055, p < .001).

Most ATs utilize computer-

based neurocognitive testing for concussion assessment
(Table 19 and Figure 5).
Table 19. Chi-Square Goodness of Fit for Concussion
Assessment Method Utilized by ATs
Type
n
χ2
p value
Computer-based Neuro70
15.055
.001
cognitive testing
Pencil and Paper
43
Grading Scale
33

A chi-square goodness of fit was used to determine
concussion assessment methods preferred by ATs.
Significant deviation from the hypothesized values was
found among the classifications of Concussion Assessment
Method Preferred by ATs (χ21 = 93.064, p < .001).

Most ATs

prefer to use computer-based neurocognitive testing for
concussion assessment (Table 20 and Figure 5).
Table 20. Chi-Square Goodness of Fit for Concussion
Assessment Method Preferred by ATs
Type
n
χ2
p value
Computer-based Neuro101
93.064
<.001
cognitive testing
Grading Scale
20
Pencil and Paper
20

30

Figure 5. Bar chart comparing utilized concussion
assessment method by ATs and preferred concussion
assessment method by ATs.

A chi-square goodness of fit was used to determine the
method of influence on ATs.

Significant deviation from the

hypothesized values was found among the classifications of
Method of Influence on ATs (χ22 = 16.545, p < .001).

ATs

state that they were most influenced by experience with the
concussion assessment methods with supported research
closely following (Table 21 and Figure 6).
Table 21. Chi-Square Goodness of Fit for Method of
Influence on ATs
Type
n
χ2
p value
Experience
56
16.545
<.001
Supported Research
54
Cost
22

31

Figure 6. Bar chart showing method of influence on ATs to
utilize concussion assessment method of choice.

Chi-square test of independence was performed among
the following variables.
Table 22 displays a 2 (Gender – female or male) X 2
(Concussion assessment method decision making – yes or no)
chi-square test of independence to determine if gender was
dependent on the decision making process for what
concussion assessment method to utilize.

A significant

interaction was found (χ22 = 4.724, p < .05).

In District 2

of the NATA, men (50%) were more likely to be the person

32
responsible for making the decision as to which concussion
assessment method should be utilized than women (41%).
Table 22. 2x2 Chi-Square Independence Test for Gender /
Concussion Assessment Method Decision Making
Type
Yes
No
χ2
P Value
Male
50
20
4.742
.029
Female
41
35

Table 23 displays a 4 (State Currently Practicing –
PA, NJ, NY, or DE) X 3 (Concussion Assessment Method
Utilized – Grading the concussion, deferring final grading
until all symptoms have resolved, or no grading, but using
symptoms, neurocognitive testing and postural stability
testing) chi-square test of independence to determine if
the state in which the AT is currently practicing was
dependent on what concussion assessment method the AT
utilizes.

A significant interaction was found (χ21 =

17.532, p < .05).

Athletic trainers within the state of

Pennsylvania (47%) were more likely to utilize the third
approach; no grading, but using symptoms, neurocognitive
testing and postural stability testing; for concussion
assessment recommended by the NATA position statement than
New Jersey (9%), New York (10%), and Delaware (2%).

33
Table 23.
Currently
Utilized
Type
PA
NY
NJ
DE
*There is

4x3 Chi-Square Independence Test for State
Practicing / Concussion Assessment Method
1
2
12
17
9
12
6
9
1
4
< 5 in a cell.

3
47
10
9
2

χ2
17.532

P Value
.025

Table 24 displays a 4 (State Currently Practicing –
PA, NJ, NY, or DE) X 3 (Grading scale, pencil and paper, or
computer-based neurocognitive testing) chi-square test of
independence to determine if the state in which the AT is
currently practicing was dependent on what concussion
assessment method the AT prefers.

A significant

interaction was found (χ21 = 17.734, p < .05).

Athletic

trainers in the state of Pennsylvania (62%) were more
likely to choose computer-based neurocognitive testing as
their preference for concussion assessment over grading
scale and pencil and paper than New Jersey (16%), New York
(16%), and Delaware (4%).

Computer-based neurocognitive

testing is also the most preferred method of concussion
assessment by all four states (PA, NJ, NY, and DE) than
grading scales and pencil and paper testing.

34
Table 24.
Currently
Preferred
Type
PA
NY
NJ
DE
*There is

4x3 Chi-Square Independence Test for State
Practicing / Concussion Assessment Method
1
2
7
6
6
7
5
3
0
3
< 5 in a cell.

3
62
16
16
4

χ2
17.734

P Value
.023

A one-way ANOVA was completed to compare the means of
ATs utilized concussion assessment methods and preferred
concussion assessment method for years of certification.
Figure 7 displays a higher utilized mean (14.05 ± 11.011)
for computer-based neurocognitive testing than the
preferred mean (13.28 ± 10.82).

The utilized mean (12.06 ±

11.42) for the pencil and paper method is lower than the
preferred mean (14.53 ± 13.138) and the utilized mean for
grading scale (13.29 ± 11.153) is higher than the preferred
mean (12.1 ± 10.857).

35
Figure 7. Bar chart comparing means between utilized
concussion assessment methods and preferred concussion
assessment method for ATs years of certification.

16
14
12
10
8
Utilized Mean

6

Preferred Mean

4
2
0
Computer-based Pencil and Paper
Neurocognitive
Testing

Grading Scale

36

DISCUSSION

The following section will include: 1) Discussion of
Results, 2) Conclusions, and 3) Recommendations.

Discussion of Results

This study focused on the most utilized tool for
assessment of sports-related concussions by certified
athletic trainers (ATs).

The AT, along with other health

care professionals, plays an important role in providing
health care to the athletic population.

Sports-related

concussions are a major sports medicine issue in the
current medical literature as well as popular media.

There

have been many guidelines constructed to allow for better
identification, assessment, diagnosis, and management of
return-to-play for athletes sustaining this serious injury.
The tools used to better assess sports-related concussions
range from standard balance screening to computerized
neurological testing.
The position statement, written by the National
Athletic Trainers’ Association (NATA) about the management

37
of sport-related concussion injuries, provides information
and recommendations for certified athletic trainers,
physicians, and other health care providers who care for
athletes in all levels of sports.

These recommendations

are derived from the most recent scientific and clinic
based literature on sport-related concussions and should be
followed by all health care providers.20

The recommendation

on evaluation and assessment of sports-related concussions
is that the ATs and team physician work together and agree
on a philosophy for managing sport-related concussion
injuries before the start of the athletic season.

The

three most commonly used approaches include: 1) grading the
concussion at the time of the injury, 2) deferring final
grading until all symptoms have resolved, or 3) not using a
grading scale but rather focusing attention on the
athlete’s recovery via symptoms, neurocognitive testing,
and postural-stability testing.18

The intent of the NATA is

to have all health care professionals who work with
athletes to focus their attention on the athlete’s recovery
based on the athlete’s symptoms, neurocognitive testing,
and postural-stability.18

The third approach to assessing

sports-related concussions is a method that is more than
one simple method of assessment, but several methods.

It

is suggested that health care providers should not use just

38
one method for assessment and return-to-play criteria of
sports-related concussions.22

This study showed that the

third approach is the most utilized among athletic trainers
in District 2 of the NATA reflected by 70% of the sample.
This finding reinforces the fact that using a multiple
method approach to assessment of sports-related concussions
is the most commonly utilized by ATs.
It was found that the third approach recommended by
the NATA’s position statement for concussion assessment,
not using a grading scale but rather focusing attention on
the athlete’s recovery via symptoms, neurocognitive
testing, and postural-stability testing, was the most
commonly utilized by ATs that were surveyed in District 2.
The third approach had the highest percentage (78.6%),
which was statistically greater than the first approach,
grading the concussion at the time of the injury (12.3%),
and second approach, deferring final grading until all
symptoms have resolved (5.2%).
The three different approaches to sports-related
concussion assessment are not a requirement by the NATA,
but it is highly recommended.

Although there is no gold

standard for assessing concussion injuries obtained by
athletes the NATA has provided a position statement for ATs
and other healthcare providers to use.

District 2 has

39
demonstrated through this research that the most commonly
used approach is the multiple method that includes signs
and symptoms, neurocognitive testing, and posturalstability testing, which is stated as the most recommended
approach of the three that are listed within the NATA
position statement.

The position statement states that

decisions about an athlete’s return-to-play should never be
based solely on the use of one concussion testing method.18
Under no circumstances should an athlete return to play if
he or she reports a symptom that is categorized under a
concussion.11,21

Management of and return to participation

following a sports-related concussion should involve a team
approach.

This includes educating the athletes, parents,

and coaches about the injury as well as collaboration with
all other medical personnel involved in the injury.21
An additional significant finding within this study
dealt with the responsibility of concussion assessment
method decision making and the influence behind concussion
assessment methods used by ATs within District 2 of the
NATA.

It was found that the majority of the ATs surveyed

within District 2 were responsible for making the decision
about what method should be used in their clinical setting
for concussion assessments.

Among the 152 ATs surveyed,

more than half replied “yes” (n=91) they were the person

40
responsible for concussion assessment methods decision
making as to what method should be utilized compared to the
“no” (n=55) responses.

This is a very important

responsibility for an AT, especially since they are usually
the first person on site when a sports-related concussion
occurs.

The sideline examination is an important part of

concussion management for an athletic trainer.

The first

item to determine during an evaluation is the mechanism of
injury, which assists in finding the severity of the head
injury.23

There have been a number of sideline assessment

tools developed, mostly for the use of athletic trainers,
to help an AT more accurately assess sports-related
concussions.

Another important aspect of the concussion

management is return-to-play decision making, which goes
hand-in-hand with concussion assessment method utilization.
Return-to-play following a sports-related concussion is the
most challenging portion of the care for a concussion
injury in making this decision.23,24

Athletic trainers are

the first on the field to assess the injury, they are the
ones who evaluate the athlete, they are the person managing
the athlete’s injury, and they are the ones who return the
athlete to play when ready.

Therefore, ATs should be the

person, or one of the people, in the healthcare team making

41
the decision about what concussion assessment method should
be utilized at their clinical site.
An additional finding was found between the concussion
assessment method utilized by ATs (Table 19) and the
concussion assessment method preferred by ATs (Table 20)
results.

There is a distinct change in the number of ATs

that use computer-based neurocognitive testing as their
method of assessment and those ATs that would prefer to use
computer-based neurocognitive testing as their method of
choice, which can be seen in Figure 5.

This is interesting

information to the profession because not every AT is using
computer-based neurocognitive testing for assessment of
sports-related concussions, but the majority (n=101) of the
population surveyed would prefer to use this form of
concussion assessment methods.

This should be brought to

the attention of the profession, where there can be
adjustments made to ensure that the majority of the ATs are
using the method that they prefer to utilize when assessing
sports-related concussions.
When looking at Figure 7 of the compared means of ATs
utilized concussion assessment methods and preferred
concussion assessment method for years of certification,
there was no significance between the utilized and
preferred choice for concussion assessments.

The means for

42
all three concussion assessment methods; computer-based
neurocognitive testing, pencil and paper, and grading
scale; were very close for utilized and preferred based on
the ATs years of certification.

This suggests that there

is no difference between how many years an AT has been
certified and which assessment method they currently
utilize or which method they would prefer to use in their
job setting.
Another additional finding identified that athletic
trainers stated that they were most influenced by
experience (n=56) with the concussion assessment methods
followed closely by supported research (n=54), then
significantly less cost (n=22).

Although many stated that

supported research was their influence to concussion
assessment methods, experience was claimed to have the most
influence on ATs in District 2.

Based on the research that

was found there are many sources that support the use of
different concussion assessment methods, whether pencil and
paper or computer-based concussion testing.

However, there

is not much supported research about ATs experience in
utilizing the different concussion assessment methods in
their clinical settings.

Athletic trainers, along with all

other healthcare providers, learn from experiences during
their educational years as well as professional years of

43
their careers.

For a healthcare provider to fully

understand the method that they are using and to determine
which is best for them, as well as for the athletic
population, they must experience each method.

Once the AT

becomes adjusted to the method and can perform the
concussion assessment with ease, they develop a comfort
level with that particular method of use.

This is how

experience works and suggests the reason the most stated
influence for utilization of a concussion assessment method
is through experience.

Conclusions

After reviewing the results for this study, it is
concluded that athletic trainers within District 2 most
commonly utilize the multiple method approach to assess
sports-related concussion, not using a grading scale but
rather focusing attention on the athlete’s recovery via
symptoms, neurocognitive testing, and postural-stability
testing, which is recommended by the NATA position
statement.

Regardless of the different concussion

assessment tools, pencil and paper or computer-based
testing, there is not one test that should be used to
assess sports-related concussion obtained by athletes.

All

44
health care providers that handle sports-related concussion
should use a range of different testing methods to
determine orientation, immediate memory, delayed recall,
concentration, and attention which are all very important
factors when evaluating a concussion.25,26 The tools used to
better assess sports-related concussions range from
standard balance screening to computerized neurological
testing, and there is no gold standard of which is more
suited for healthcare providers.
Research on the topic of sport-related concussions has
provided the athletic training profession, as well as other
medical professions, with valuable new knowledge over the
last few years.

The key to reducing the incidences and

severity of these injuries, in addition to improving
assessment of sports-related concussions and return-to-play
decisions, is found in connecting the gap between research
and clinical practices.

Recommendations

Further research recommendations for this study, first
and foremost, include surveying other districts within the
NATA.

This would give a better picture of what would be

the most commonly utilized approach to sports-related

45
concussion assessment among other ATs in many different
locations.
Another possible area to be researched is educational
background of concussion assessment methods indicates a
difference in what recommended approach ATs prefer to
utilize in their career settings.

In addition, further

research needs to be done regarding undergraduate and
graduate exposure to concussion assessment methods.
Further research needs to be done in regards to the
number of ATs who stated that they used computer-based
neurocognitive testing and the ATs who preferred to use
this same testing method.

The reasons why these ATs are

not using the computer-based neurocognitive testing when
they would prefer to utilize this assessment method need to
be determined.

46
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Iverson GL, Lovell MR, Collins MW. Validity of ImPACT
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Majerus S, Van der Linden M, Shiel A. Wessex Head
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Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly
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49

APPENDICES

50

APPENDIX A
Review of Literature

51

Review of the Literature

Sports-related concussions are a major sports medicine
issue in the current medical literature as well as popular
media of today.1

There have been many guidelines

constructed to allow for better identification, assessment,
diagnosis, and management of return-to-play for athletes
sustaining this serious injury.

The tools used to better

diagnose and assess sports-related concussions range from
standard pencil and paper assessment testing to
computerized neurological testing.
There are several sets of grading systems and
guidelines for the management of sports-related concussions
that have been published.

In fact, there are over 16

grading scales and three of these are most commonly used by
healthcare providers.2

Therefore, the purpose of this

review of the literature is to discuss sports-related
concussion diagnosis, assessment, and concussion testing
methods to determine which may be better suited for the
athletes as well as the healthcare providers.

The review

of literature consists of the following sections and
subsections: 1)Sport-related Concussion Injuries,
1a)Definition of Concussion, 1b)Sideline Evaluation,

52
1c)Management Guidelines, 1d)Return-to-Play, and 1e)When to
Refer; 2)Concussions in Athletes, 2a)Contact Sports and
Concussions, 2b)High School vs. Collegiate Level Sports;
3)Concussion Assessment and Diagnostic Tools, 3a)Computer
Based Concussion Testing, 3b)ImPACT, 3c)CogSport,
3d)HeadMinders CRI, 3e)Glasgow Coma CRI, 3f)Sideline
Assessment Testing, 3g)Standardized Assessment of
Concussion (SAC), 3h)Balance Error Scoring System (BESS);
and an overall summery.

Sports-related Concussions

Sports-related concussions or mild traumatic brain
injury (MTBI) in athletics is a major issue in the world of
athletics.

Reports have shown concussion injuries in

multiple sports and the trend of this traumatic brain
injury has been increasing in occurrence over the past
several years.1 There has been great attention given to the
research of this injury to form a better understanding in
terms of athletes health concerns, from the time of injury
throughout their lifetime.

Still, many issues remain in

relation to the diagnosis, assessment, and management of
sports-related concussions.

This review will discuss the

anatomy and physiology of concussion injuries in addition

53
to the sideline evaluations, grading scales, management
guidelines, and return to play criteria of sports-related
concussions.

Definition of Concussion
There are numerous definitions of concussions in
today’s literature such as Dr. Robert Cantu’s definition of
“a traumatically induced alteration of mental status”.3(p75)
The term “concussion” comes from the Latin word concutere,
meaning “to shake violently”.4-6

The Congress of

Neurological Surgeons came to the following conclusion in
1966 that the definition of a cerebral concussion was “a
clinical syndrome characterized by the immediate and
transient posttraumatic impairment of neural function such
as alteration of consciousness, disturbance of vision or
equilibrium, etc. due to brain stem involvement”.4(p150)

The

definition consensus of the American Academy of Neurology
is “any trauma-induced alteration in mental status that may
or may not include loss of consciousness”.7(p674)

In 2001 in

Vienna, Austria, the First International Symposium on
Concussion in Sport came to an agreement that concussions
were defined as “a complex pathophysiological process
affecting the brain, included by traumatic biomechanical
forces”.8(p964)

It is stated that a concussion results in a

54
graded set of clinical symptoms that may or may not involve
loss of consciousness.5,9

Through all of these definitions

and explanations of cerebral concussions there will be
modifications made due to new research on this topic.8
None of these definitions consider loss of consciousness as
a defining characteristic of a concussion, but the loss of
consciousness may or may not be present as one of the
symptoms of a concussion injury.7

This injury is

characterized by a number of postconcussion symptoms, which
include but are not limited to, headache, nausea,
lightheadedness, amnesia, and confusion.3

Other symptoms

may present, such as loss of consciousness, blurred vision,
attention problems, drowsiness, balance problems, sleep
disturbance, photophobia, emotional liability,
irritability, and vacant stare.

Concussion injury may

possibly result in neuropathological changes, although the
acute clinical symptoms listed above do largely reflect the
functional disturbance of the brain more so than the actual
injury.10
The current and most recently updated definition of
concussion is presented by the Center for Disease Control
and Prevention (CDC).

The CDC revised educational

materials for healthcare providers treating concussions and
MTBI and as part of their revision they have updated the

55
definition of concussion to reflect current medical
opinion.11

The CDC defines concussion or MTBI as the

following: “The term mild traumatic brain injury is used
interchangeably with the term concussion. This is defined
as a complex pathophysiologic process affecting the brain,
induced by traumatic biochemical forces secondary to direct
or indirect forces to the head. MTBI is caused by a blow or
jolt to the head that disrupts the function of the brain.
This disturbance of brain function is typically associated
with normal structural neuroimaging findings (i.e., CT
scan, MRI)”.11

Sideline Evaluation
The sideline examination is an important part of
concussion management for an athletic trainer.

If the

environment or location where the athlete’s injury
occurred, such as the sideline of a sports field, is not
appropriate for evaluating that athlete then they must be
transferred to a different location, a locker room or any
other facility that is available will be more suitable.8,10
The first item to determine during an evaluation is the
mechanism of injury, which assists in finding the severity
of the head injury.10

The most common mechanisms of

concussions occur when the athlete has contact with either

56
another athlete, the playing surface, or some other
component of the playing field.

Concussion injuries will

typically present as a period of confusion, amnesia, and
possible disorientation.

An athlete with a concussion may

have a very obvious presentation, such as a direct blow to
the head, loss of consciousness (LOC), and amnesia.8,10
However, there are still those who have more subtle signs
and symptoms after sustaining a head injury.

A few

individuals will experience ringing in the ears or seeing
“stars”, which occurs only for a few seconds or minutes and
then vanish.8
There have been a number of sideline assessment tools
developed, mostly for the use of athletic trainers, to help
a more accurately diagnose sports-related concussions.10
For example, online assignments should always include a
high-quality past medical history and injury history taken
with each concussion.

Furthermore, the online assignment

should include orientation, immediate memory, delayed
recall, concentration, and attention are very important
factors within a concussion evaluation.8,10

Management Guidelines
All athletes that sustain a concussion injury require
a thorough evaluation followed by very close monitoring.

57
There are more than 18 different concussion grading scales
that have been published in past literature.

It is

unfortunate that none of these 18 scales for concussion
severity are solidly evidence-based, however they do
represent the clinical opinions of experts.10 It is
exceedingly important for the healthcare providers of those
with concussions to take the time to familiarize themselves
with a single set of guidelines to help organize the injury
evaluation process.

The most common guidelines used by

healthcare providers today were developed by Cantu, the
Colorado Medical Society, and the American Academy of
Neurology.8,10

Each of these scales are based on the

severity of the cerebral concussion due to the presence and
length of any period of unconsciousness.

The scale ranges

from grade one and grade two, mild to moderate, and ends
with grade three being severe.
When looking at the different symptoms linked to a
sports-related concussion injury there are many to consider
within the management guidelines.

The most common

postconcussion complaint is a headache.

The symptom of a

postconcussion headache can either be focal or generalized
and may not fully manifest until hours or even days after
the concussion occurred.8

Most postconcussion headaches

usually worsen during physical exertion because during

58
activity the brain moves within the skull causing more
damage, which is why there is a great importance in
assessing the athlete during rest as well as activity.

If

the headache continues to get worse or if it is accompanied
by vomiting or deteriorating mentation, the athlete should
immediately be referred to a hospital for further
investigation and physician based medical care.

Another

common symptom is the complaint of vision disturbance, one
that needs to be carefully assessed.8,9

The athlete might

have impaired vision tracking, loss of acuity,
photosensitivity, and changes in peripheral vision.

All of

these symptoms should be fully resolved before the athlete
can return-to-play.8

The occurrence of seizures that

present themselves immediately after impact are often
benign and should not have a prolonged state.

Medications

are not usually warranted because the seizure is short
lived and very rarely leads to more spontaneous seizures.
One substantial concern in the management of concussions
are multiple concussion occurrences.

When this injury to

the brain is repeated, it may cause cumulative cognitive
effects and slower recovery of neurological functioning of
the brain.

There is not a consensus as to how many

concussions are too many for an athlete to sustain.6

59
Since there are so many management guidelines out
there to be used, not one has been decided on as the
ultimate guideline in managing cerebral concussion
injuries.

This concludes that no real valid guidelines for

management of sport-related concussions exist.7

The CSG and

the Canadian Academy of Sports Medicine has an outlined
approach for immediate response following the recognition
of any signs or symptoms of a concussion.9

Their statement

is that the player should not be allowed to return-to-play
in the current game or practice, they should not be left
alone and regular monitoring for deterioration is
essential, they should be medically evaluated after the
injury, and return to play must follow a medically
supervised stepwise process.7

Return-to-Play
The most challenging portion of the care for a
concussion injury is making the decision on return-to-play
following the injury.10,12

There can be a lot of external

pressure from individuals such as coaches, parents, and the
patient to return the athlete to competition early.10
Preventing athletes from returning to their sport for
unnecessarily long periods of time may have a significant
impact on the athlete’s career, financial viability, and

60
psychological functioning.13

However, there is still a

great importance in return to play decisions and there
should be no rush in making a premature decision which puts
the athletes health at risk.

There are many clinicians

that believe the return-to-play guidelines are too
conservative and they choose to base their decisions on
clinical judgment of individual cases instead of on the
general recommendations.14

Many of these return-to-play

guidelines call for the athlete to be symptom free before
they can continue their participation in a sport.
Returning an athlete to participation should follow a
progression that begins as soon as the athlete is
completely free of concussion symptoms.

All the signs and

symptoms of the injury should be evaluated using a graded
scale or checklist when performing any follow-up
assessments and the athlete should be evaluated both at
rest and after physical activity whether it be biking,
jogging, sit-ups, or even push-ups.

If the athlete does

not reproduce symptoms after physical activity the athlete
is then allowed to participate in sport-specific skills and
eventually allowed to return to practice.

The athlete

should remain out of any activities or drills that would
put him or her at risk for another head injury.

61
The Cantu guidelines on return-to-play following
different types of concussion are widely recognized in the
medical community as the most useful.4,10,13

This scale was

proposed in the year 1986 and was developed through
clinical experience and uses of loss of consciousness and
posttraumatic amnesia as the markers for concussion
severity.3,8,14

Athletes returning to play the same day they

receive a concussion are allowed when the athlete sustains
a grade 1, mild, concussion and only when they are
asymptomatic at rest and with exertion.3,14

The athletes

that experience a grade 2, moderate, concussion are allowed
to return-to-play in two weeks, but only if they are
asymptomatic for one week.3

With a grade 3, severe,

concussion the athlete is allowed to return-to-play in one
month, but only if they are asymptomatic for 1 week.3,14
When looking at the Sports Medicine Committee of the
Colorado Medical Society, which was published in 1991, they
are quite different compared to Cantu’s.10

The guidelines

for a grade 2 concussion where the athlete does not sustain
loss of consciousness (LOC), but suffer from confusion with
amnesia, the athlete is allowed to return to play the same
day as long as they are asymptomatic during 20 minutes of
observation.13,14

However, it is recommended that an athlete

62
experiencing a grade 2 with LOC or grade 3 concussion
should be immediately referred to a hospital.14
There is also a great difference in the guidelines
formed by the American Academy of Neurology, which put
emphasis on the symptoms of confusion, amnesia, and loss of
consciousness.10,15

Return-to-play for an athlete with a

grade 1 concussion is the same day, only if they are
asymptomatic for 15 minutes during observation.10,15,16

For

those athletes with a grade 2 or grade 3 concussion, the
minimum time recommended before return-to-play is one week
and for those with multiple concussions the recovery period
recommended is one to four weeks, depending on the
grade.15,16
The gold standard for deciding return-to-play
continues to be a clinical evaluation of symptoms and a
complete neurological examination.10

Neuropsychological

testing, which is performed by the healthcare provider, is
a valuable tool for objective evaluation of the athlete’s
cognitive function following a concussion injury.

When to Refer
Most sports-related concussions are considered mild
head injuries, but there is still potential for more
serious complications and other life-threatening injuries

63
to arise from a concussion.14

Sports-related concussion

injuries or MTBI can become very serious matters in some
cases.

The healthcare provider must base the need for

referral on his or her own clinical judgment.

Each

provider should be concerned about the potential for the
injury condition of an athlete to deteriorate.

A downward

spiral can occur within minutes or hours or even several
days after an athlete sustains a concussion.6

There must be

a recognition that these injuries require further attention
and the athlete should be provided with the appropriate
referral for advanced care.

Serial assessments and

physician follow-ups are important factors of the
evaluation process for an athlete with a concussion.

These

athletes are to be referred to medical personnel, who have
the experience in managing sports-related concussions.
Vital signs and level of consciousness should be monitored
every five minutes after the injury and continued until the
athlete’s condition is stable and improves.

The athletes

should also be evaluated over the next few hours and days
following the injury for any sign of delayed symptoms
during the recovery period.
There is the possibility of a long-term neurocognitive
impact on an athlete from a concussion injury, which can
suggest a chronic traumatic brain injury.10 This serious

64
injury has been studied over the years with no clear answer
as what has to be done in this case.

Some studies have

provided some supportive information about chronic
traumatic brain injuries, but further research needs to be
done to answer the lingering question of whether these
severe injuries occur as a result of concussions or that
they are simply related to the athletes sport
participation.
There are several indications for an acute concussion
injury referral such as evidence of a subdural or epidural
hematoma, suspected cervical spine injury, deteriorating
level of consciousness, transient quadriparesis, and
seizure activity.10 Some other indications for referral are
persistent headaches and other symptoms that linger for
more than one week after injury, postconcussion syndrome
two weeks following the injury, and pervious history of
multiple concussions in playing career.

Concussions in Athletes

Incidences of sports-related concussions continue to
increase, which is a factor for the number of the total
sports activities, the number of previous sports years of
adolescents, and the level of athletic participation that

65
also continue to increase.17

Nearly 1.5 million head

injuries occur in the United States each year and roughly
20% or 300,000 of these injuries are sports-related
concussions.18-21

About 19% of those injuries occur during

contact sports participation, such as football and rugby.12
Some other popular sports that hold a higher number of
concussion incidences are soccer, wrestling, ice hockey,
field hockey, snowboarding, martial arts, and lacrosse.7

Contact Sports and Concussions
Competitive sports participation has increased
worldwide and the sports-related concussion injury
represents a very significant health concern for all
athletes participating in a contact sport.1

The sports that

involve impact to the head such as American football,
rugby, boxing, martial arts, soccer, and ice hockey provide
an opportunity to explore the effects of concussions as
well as multiple concussions within contact sports.22
Football and rugby are two big contact sports where there
is body contact between opposing players, which occurs
routinely during each game play.23

The sports of boxing and

martial arts involve forceful contact between opposing
players because of the requirement for earning points
during matches.

When looking at ice hockey and soccer

66
there are special circumstances in each sport that may
predispose a player to head injury.

Ice hockey puts

athletes at risk of concussion because of the speed at
which body contact occurs as well as the surfaces that
opposing players are checked against.

The game of soccer

includes heading of the soccer ball that also puts the
athlete at risk for concussion.
Most of the head injuries in youth athletics are mild
traumatic brain injuries and the highest amount of these
injuries occur in the sport of American football.7

It is

stated that the risk of sustaining a concussion in football
is four to six times greater if the player has already
experienced a concussion.22

Permanent brain injuries due to

multiple concussions have been reported
ice hockey and football.

on both sports of

There is a particular concern in

the competition at the high school level, where at least
1.25 million athletes compete in a contact sport.17

High School vs. Collegiate level Sports
The rate of concussion injuries have appeared to
increase in both collegiate athletes and high school
athletes, high school athletes are sustaining concussions
at a greater rate in sports compared to collegiate level
playing.17

Studies of high school and collegiate athletes

67
indicating that cumulative effects may result from three or
more concussive episodes show the importance and
seriousness of sports-related concussions.20

The

participation in high school and collegiate athletics
continues to increase in numbers, with more than seven
million high school students participating between the
years of 2005 and 2006 and almost 385,000 collegiate
students participating between the years of 2004 and 2005.13
This indicates that the number of student-athletes
sustaining concussions may also increase unless preventive
measures continue to progress.

The majority of these

concussions happen at the high school level of athletics,
where there are over one million high school students
participating in the sport of football.13 In the high school
setting there are over 62,000 football players that receive
a concussion injury every year, whereas only 34% of the
collegiate football population have been diagnosed with one
concussion and only 20% of those have been diagnosed with
multiple concussion injuries.12,22
When discussing the brain injuries in children and
adolescents there must be one factor taken into
consideration, which is the inherent differences between
children and adolescents and adults.7

The higher incidence

of concussion rates in adolescents may simply be a result

68
of younger, more susceptible brains.17

Increased

susceptibility to brain injuries in children and
adolescents, compared to adults, has been linked to
decreased myelination, greater head-to-body ratio, and
thinner cranial bones, that all lead to less protection of
the developing cortex of the brain.

There is a

developmental process and when comparing age and maturity
there has to be some knowledge of how it may interact and
affect the nature of the injury and its outcome.7 It can be
argued that most of the current management guidelines meant
to handle this injury are not applicable to children and
adolescents because the knowledge and research is limited.
A college sports arena is complicated when it comes to
addressing concussions, but a high school sports setting is
even more challenging.1

In high school athletics there are

coaching positions and sports medicine positions assigned
to multiple sports teams and they may be performed by
individuals who are only part-time.

At the high school

sports setting there may be concussions that go unnoticed
or unmanaged and this is a huge concern because the typical
high school athlete is at more risk for sustaining a
concussion due to age and sports skill level. As the
participation in high school athletics continues to

69
increase healthcare providers will continue to be heavily
relied upon to diagnosis and treat concussion injuries.20

Concussion Assessment and Diagnostic Tools

Sports-related concussion assessments should include
testing for postural stability, cognitive function, and
self-reported symptoms.18

Some examples of these sports-

related concussion screening instruments include sideline
evaluations, such as the Standard Assessment of Concussion
(SAC) and the Balance Error Score System (BESS), and the
most recent computer based concussion testing, such as
IMPACT, CogSport, and Headminder CRI.

These neurocognative

tools assist the healthcare provider in evaluating and
documenting memory, brain processing speed, reaction time,
and postconcussive symptoms.

The results of these tests

should be interpreted in light of all the other factors
pertaining to the injury, which may include physical exam,
age, gender, and previous concussion history to help in
return-to-play decision making.

The more recently created

assessment tools have been found through research to be the
most helpful and more effective in making these critical
return-to-play decisions.24

70
Sideline Assessment Testing
Once an athlete has been suspected of sustaining a
sports-related concussion, a physician must be involved in
the return-to-play decision, but the problem is that the AT
is often the person that manages the injury alone on the
sideline.25

The sideline assessment for concussions begins

before the competitive season has started.

The nature of

concussion injuries are highly variable and mandate an
individualized approach to injury management.

The use of

baseline assessments of each athlete, when they are injury
free, seem to give healthcare providers a step up on this
injury’s management.

Regardless of the tests performed,

the evaluation should include measures of concussion
related symptoms, postural control, and neurocognitive
function.14,25

When an athlete is evaluated following a blow

to the head, the previously collected data can be used to
objectively identify post injury change that will support
the decision for return-to-play based on the clinical
examination.25

There are many different sideline assessment

tests that have been created to help the AT standing there
alone on the sideline at a game and they all can be used to
help the determination of return-to-play decisions.

71
Concussion Grading Systems
The concussion grading systems are sets of criteria
used in sports medicine to determine the severity, or
grade, of a concussion injury.25

There are at least 18 such

systems that exist, and several of the systems use loss of
consciousness (LOC) and amnesia as the primary determinates
of the severity of the concussion.26

These systems were

widely used to determine when it was safe to allow an
athlete that had sustained a concussion to return to
competition.

The three most commonly known concussion

grading systems were developed by Robert Cantu (Cantu
guidelines), one by the Colorado Medical Society, and a
third by the American Academy of Neurology.26

Cantu Guidelines
Robert Cantu published the Cantu guidelines in 1986 to
classify an injury associated with no loss of consciousness
(LOC) and less than 30 minutes of post-traumatic amnesia as
grade I.25

The Cantu grade II is determined when the

patient loses consciousness for less than five minutes or
experiences amnesia for between 30 minutes and 24 hours.
In grade III, loss of consciousness (LOC) lasts longer than
five minutes or amnesia lasts longer than 24 hours.10

72
In the year 2001 there was an update to the Cantu
guidelines made to include other concussion signs and
symptoms in addition to amnesia in the grading system.10
Cantu also changed the grade II criteria to include only
concussions with loss of consciousness (LOC) for less than
one minute as well as those with loss of consciousness for
greater than one minute, or with signs and symptoms lasting
over one week, under the criteria of a grade III
concussion.25

Colorado Medical Society Guidelines
The Colorado Medical Society guidelines were published
in the year 1991 in response to the death of a high school
athlete due to what was thought to be second-impact
syndrome.26

According to these guidelines a grade I

concussion consists of confusion only whereas a grade II
includes confusion and post-traumatic amnesia, and a grade
III (LOC for seconds) and IV (LOC for minutes) all involve
LOC.26

By these guidelines, an athlete who had sustained a

concussion may return to play after having been symptom
free both at rest and during exercise.
Grade I states that for the first concussion the
athlete should be held from participation for 15 minutes
and for subsequent concussions for one week.

For a grade

73
II concussion injury the athlete should be held from
participation for one week for the first concussion and two
weeks (with physician approval) for subsequent concussions.
Grade III (LOC for seconds) has the athlete held from
participation for one month for the first concussion and
six months (with physician approval) for subsequent
concussions.

The final grade IV (LOC for minutes) the

athlete is held from participation for 6 months with the
first concussion and one year (with physician approval) for
any subsequent concussions.10,26

American Academy of Neurology Guidelines
The American Academy of Neurology (AAN) published
concussion grading guidelines in the year 1997, which are
based on those by the Colorado Medical Society.27

According

to these guidelines, a grade I concussion is associated
with no LOC and symptoms of confusion last less than 15
minutes.

Grade II is the same, except that the symptoms

last longer than 15 minutes.

For grade III, loss of

consciousness does occur and this can be divided further
into grades IIIa and IIIb, with brief LOC (seconds) and
prolonged LOC (minutes).25

The AAN guidelines state that an

athlete suffering from a single, grade I concussion is
given a neurological evaluation every five minutes starting

74
immediately after the injury and may return-to-play if
signs and symptoms resolve within 15 minutes.27

Otherwise,

the return-to-play guidelines are the same for the AAN and
Colorado Medical Society guidelines.

Pencil and Paper Assessment Testing
There are many different versions of pencil and paper
assessment testing, such as SAC and BESS, which were
developed as sideline assessment tools to help ATs and
other healthcare providers on the sidelines of athletic
practices and competitions for quick initial concussion
assessment.6,7,24,29

These tests are standardized tools with

which a sports-related concussion can be evaluated
immediately after sustained by an athlete.

Most pencil and

paper tests are comprised of four components: orientation,
immediate memory, concentration, and delayed recall.7,17,24,29
The benefits of pencil and paper testing is ease and
brevity of administration as well as scoring and alternate
forms for follow-up assessments while tracking the
athlete’s recovery.17

Standardized Assessment of Concussion (SAC)
The popular computerized tests are purported to offer
many advantages over paper and pencil test, but both

75
assessment techniques are limited to the athletic training
room or other controlled environments.28

To remedy this

shortcoming of technology, the Standardized Assessment of
concussion (SAC) was developed as a brief concussion
screening tool for sideline administration and has proven
to be effective in the assessment of acutely concussed
athletes.6,28

This assessment test is different from those

of comprehensive paper and pencil or computer based
neurocognitive assessments specifically for the purposes of
administration as well as interpretation.24

These

characteristics make this evaluation process ideal for
administration on the sidelines and only require about five
to six minutes to complete.6,23

This test consists of four

different sections that evaluate the areas of orientation,
immediate memory, concentration, and delayed recall, which
makes it a brief screening and rules out gross neurological
deficiencies.7,24,29

There are alternate forms of the SAC

test were designed and offered (A, B, and C) to minimize
practice effects during follow up testing.29

The SAC

orientation section was assessed by asking the athlete to
provide the day of the week, the date, the month, and the
time.29

A five word list of unrelated terms was used to

measure the immediate memory and the list is read to the
athlete, who then is to repeat the words back to the test

76
administrator during a total of three trials.

The SAC

concentration section is assessed by having the athlete
repeat strings of numbers and by reciting the months of the
year in a reverse order.

The last section, delayed recall,

goes back to the five word list that was previously used in
the immediate memory, and the athlete is asked to deliver
as many of the words from that list they can remember.

It

gives a numerical score, maximum of 30, that is compared
with the athlete’s baseline score and a player that has
sustained a concussion will typically have scores below
their baseline.5

Another great characteristic of this

sideline test is that it has been found effective and
appropriate to use on youth, nine to fourteen year old,
athletes.29
There has been an increase in use and application of
computerized assessment in the evaluation and management of
concussions, which include immediate sideline assessment of
these injuries.7

An electronic version of SAC, called eSAC,

has been created by the people of Sideline Assistant and
HeadMinder Inc., and can now be used for sideline
assessment.

This handheld device records symptoms and

determines the return to play parameters.

The information

collected within the eSAC is later synchronized and
integrated on an internet based computerized

77
neuropsychological assessment tool known as the Concussion
Resolution Index, Headminder CRI.29

Balance Error Scoring System (BESS)
Recently, instrumented and non-instrumented postural
control assessments have been used to evaluate sportsrelated concussions in athletes.28

The Balance Error

Scoring System (BESS) is a brief, non-instrumented
assessment of balance.

BESS was created as an objective

postural control measure that can be implemented easily on
the sidelines of a sports field as well as the athletic
training room.24,30,31

This test is a rapid and easy way to

administer a sideline assessment and it is very
inexpensive.32

Following a sports-related concussion, the

athlete being assessed will commonly commit more errors on
the BESS test compared to their baseline evaluation, this
indicating a decrease in postural control.28

The primary

objective of the BESS test is to provide healthcare
providers with an immediate measure of postural control
when assessing an athlete with a potential MTBI, during a
sideline clinical evaluation.31
The BESS test is conducted under six stance
conditions, a double-leg stance, a single-leg stance, and a
heel to toe tandem stance, which are all performed on a

78
firm surface and then on a compliant foam surface.24,29,32
Each of these three different stances are evaluated for 20
seconds and the athlete is required to place his or her
hands on the hips with the eyes closed during this time.
During the trials there are a number of errors that the
athlete may commit and the errors are counted and the
higher the number represents suppressed balance.24

The

errors include opening of the eyes, stepping, stumbling,
and falling out of the test position, lifting the hands off
the hips, lifting the toes or heels, moving the leg into
more than 30 degrees of flexion or abduction, and remaining
out of the test position for more than five seconds.29

An

increase of three counted errors or more over the baseline
score may represent a significant change, which is
indicative of a balance impairment.24
Researchers in sports medicine have reported that the
BESS test performance can be influenced by a number of
different factors.32

The first factor of influence is that

there can be performance differences attributed to the
sport of the athlete, who is performing the assessment.
For example, sports such as ice skating and gymnastics
require their athlete to have excellent static balance
compared to those involved in sports like football and
basketball.

The second factor is that the BESS performance

79
can be adversely affected by exertion and fatigue, but this
factor is short lived with normal performance returning in
roughly twenty minutes.

The next factor is that the BESS

performance is worse in athletes with a history of ankle
injuries and ankle instability, which can greatly affect
the final error score.

The fourth and final factor is that

the BESS performance can show a learning or practice
effect, especially when the test is administered over and
over again in brief re-test intervals.

One very good

effect of this postural control assessment test is that it
has been proven to be effective and appropriate to use for
youth athletes, ages nine to fourteen years old.29

Computer-Based Concussion Testing
The assessment of sports-related concussions have
received an increasing amount of attention over the past
few decades.33

During this time neuropsychologists,

athletic trainers, and other healthcare providers have
tried to better understand and document the behavioral
sequence that follows a cerebral concussion.

Computerized

testing plays a particularly important role in the sports
related concussion arena in today’s world.

Most of the

concussion injuries sustained by athletes involve
relatively mild symptoms and with the ability to use these

80
tests the factor of baseline testing of athletes has shown
to be a very powerful assessment tool.
When there is the ability to compare pre- and
postconcussion neuropsychological data, there is also the
ability to differentiate changes in the neurocognitive
status of an athlete with a concussion injury.33

In

addition, the healthcare provider is able to evaluate the
degree of symptom resolution in the athlete as well.
Computer based assessment testing along with accurate
timing of evaluation may be the best suited tool to
identify neurocognitive deficits, progress towards full
recovery, and provide helpful assistance in return-to-play
decisions.

CogSport
This tool is operated through CogState Ltd., created
in Victoria, Australia, and is a standalone computer
software product that measures the reaction time and
accuracy to evaluate the simple and complex attention of
the athlete, as well as the working memory, short-term
memory and new learning, incidental memory, adaptive
problem solving, continuous performance, and spatial
abilities of the athlete.30,34-36

The task stimuli of this

program is to take the form of playing cards to create a

81
game-like atmosphere, which are presented either as
individually or grouped, with specific response
requirements.34,36 This administration takes only 15 to 20
minutes to complete and the results are submitted to
CogState for scoring and analysis.34,35

The program contains

measures of speed, accuracy, and consistency for responses
and there appears to be a total of eight scores produced
from the domains of psychomotor, decision making, problem
solving, and memory and no overall index score.35

There are

optional services as well that include customized reports,
custom data that could be imported into popular statistical
packages, storage and retrieval of data and results, as
well as mirroring of stored data for increased security.34
CogState also offers assistance in interpretation of the
results used for publication or presentation and assistance
in preparation of research protocols or IRB submissions.29,34
The main reason for this program’s design is to evaluate
changes in cognitive function and for good test-retest
coefficients and external validation.34

HeadMinder CRI
The Concussion Resolution Index, produced by the
HeadMinder, Inc., located in New York, New York, and more
commonly known as HeadMinder CRI, offers an online

82
neurocognitive and neurobehavioral assessment instrument in
this form of sideline assistance to healthcare
providers.30,34-36

The CRI is internet based and all subtests

that it offers are administered online through an internet
browser.34-36

The result of this is a program that is

computer platform independent.

CRI test takes

approximately 20 to 25 minutes to complete and the measures
are scored online and the results are then accessible for
interpreting and discussion test results with the
athlete.34,35

This program, in 2003, was greatly used by

numerous professional, semiprofessional, club, collegiate,
and high school athletic programs.34

The program’s six

subtests are designed to measure reaction time and speeded
decision making, which reported a strong concurrent test
validation.34-36

There are two reaction time subtests and

two memory subtests.35

The other two subtests use a

continuous recognition type of formatting where the
subjects are presented with a series of pictures where some
of the pictures are repeated.

For these subtests the

athlete is instructed to press the spacebar on the key
board whenever they recognize a previously presented
picture.

However, the CRI was found to be sensitive in

identifying post-concussion symptoms, if remained resistant
to retest effects.34,36

This computer-based program also

83
includes an internal symptom validity measure to screen for
chance responding or any possible decreased baseline test
performance that is significant.34

The other down fall to

this computer based program is that there is no overall
index score presented in the results when the test is
completed.34
Computerized assessment is not without its faults or
disadvantages.

Researchers have pointed out that these

automated procedures are creating a false sense of ability
such that anyone may be able to diagnose perceived
neuropsychological deficits with the help of only a
computer.36 For healthcare providers, computerized
assessment may encourage a passive stance during clinical
evaluation, rather than taking an active role to present
visual stimuli that can be verbally stated, such as words
presented visually for recall or other cognitive
comparisons.

The research literature is not in complete

agreement with respect to the psychometric equivalence of
computerized versus the original paper and pencil
assessment measures.

Computer programs are able to analyze

data, but they are not capable of interpreting the clinical
meaningfulness of the data being collected.
The future of sports-related concussion assessments
and diagnosis should and will include the use of

84
computerized baseline assessment of athletes.34

The three

main programs that were discussed above and currently on
the market for purchase show the documentation of
reliability and validity of assessment measures in today’s
research literature.

These three computer based

instruments, whether they are computer lab programs or web
based programs, are very sensitive to neurocognitive
functioning and they are all designed to augment, not
supplant, clinical decisions on return-to-play.6

These

tests may represent the most critical issue for the long
term success of computer-based assessment of sports-related
concussion and in addition establish a utility and
sensitivity to the sequence of cerebral concussion
injuries.34

ImPACT
The Immediate Post Concussion Assessment and Cognitive
Testing (ImPACT) is the most recent of the computer-based
neuropsychological test batteries formed by the ImPACT
Application in Pittsburgh, Pennsylvania.18,30,37

This tool

requires about 20 to 25 minutes to complete and it is
designed to measure the attention, memory, processing
speed, and reaction time of the athlete to 1/100th of a
second.6,12,18,35,37

It is a Windows based program that also

85
consists of a self-report system questionnaire and a
concussion history form.

There are six individual test

modules, each with its own multiple associated scores, that
measure aspects of cognitive functioning, including
information processing speed, attention, memory, and
reaction time.12,20,21,35,37

The memory index is comprised of

five subtest scores that measure the different aspects of
memory including verbal learning and recognition memory,
visual associative memory, visual working memory, and
letter memory.20,21,34,36

This composite index represents the

average percent correct score for these five subtest
scores.21
The ImPACT test battery is designed to minimize the
practice effects by randomizing the stimuli being presented
in the test.11,21

Presentation of all stimuli within the

test, except for the recognition of word memory, is varied
automatically for each examination.21,36

The verbal memory

composite score of the ImPACT test represents the average
percent correct for a word recognition task, a symbol
number match task, and a letter memory task with an
accompanying interference task.38,39

This index yields the

percentage of the correct recognition scores for both
learning and delayed recognition.21

During the visual

memory composite, the “X” and “O” task, the athlete is

86
required to mouse click the left button if a blue square
appears on the screen and right mouse click if a red circle
appears.21,35

This index score represents the average

percent correct scores of 2 tasks, recognition memory and
identification memory.39

The reaction time index represents

the average time, in seconds, the athlete takes to
respond.11,21,36-39

All stimuli are randomized, as well, to

minimize practice effects.21

There are three scores used to

calculate the composite score of this index.21,38

The

processing speed composite represents the previously
mentioned symbol match task also located in the verbal
memory composite score.37-39

In the impulse control

composite the athlete is presented with three words (red,
green, or blue) in the same color ink of the word or in a
different color ink from the word.21

The athlete is

required to respond rapidly while inhibiting the impulse to
respond to the non-target words.

This composite is used to

identify the athletes who are seriously confused about the
test instructions or who might have made numerous right or
left confusion errors.37-39

There is a total of five index

scores, but no overall index score, shown in the results of
this test, but there is a self-reported symptoms scale that
is included in this program.12,26,35

The postconcussion

symptom scale consists of 21 symptoms that are commonly

87
experienced with sports-related concussions.11,21

The

athlete is asked to choose, mouse click, the point on the
scale that most accurately reflects his or her status with
regard to each of the symptoms at that time.
In 2003, approximately 200 high schools, intercollegiate
athletic programs, and professional teams were using
ImPACT.34

During this year IMPACT was utilized by 9 of the

11 Big Ten football teams, as well as teams in the Pacific10, Southeastern Conference, and Big XII alone.

When

looking at the professional level of sports this program
was used by teams in the National Football League, Major
Baseball League, and the umpires of Major League Baseball,
as well as the National Basketball Association starting in
2003.34,35

There was also use of ImPACT in the Championship

Auto Racing Teams and the United States Olympic Women’s
Hockey Team.34
Research evaluating the reliability and validity of
change using ImPACT has shown this testing instrument to be
an effective tool in concussion assessment and
management.20,37

The initial research on ImPACT reveals that

the system produces strongly reliable and validated data.34
The processing speed and reaction time composites of the
ImPACT are found to correlate highly with a standard
neuropsychological so called paper and pencil test of these

88
two domains.38

Furthermore, test-retest coefficients for

this the ImPACT composite scores indicated a high degree of
reliability that is similar to other neuropsychological
tests of today.39
The more recent research has focused on the
sensitivity and specificity of the ImPACT tool and had
indicated its utility as part of a formal concussion
management program.37

This test has demonstrated good

sensitivity and specificity in prior studies done with
young athletes.20,38

There have been numerous testing and

retesting done with this program and there is sure to be
additional testing in future medical literature.

Summary

There is no doubt that sports-related concussions
remain to be one of the most complicated injuries faced by
athletic trainers and other healthcare providers.24

The

injury typically shows no visible signs, which leaves a
heavy reliance on the watchful eye of medical professionals
to detect subtle differences in the injured athlete.7,24
Furthermore, there is no diagnostic test available for this
injury, which leaves the clinical examination and a battery
of indirect objective tests as the primary means of

89
clinical diagnosis.24

This clinical examination of a

concussion injury should follow the same systematic process
used for all other orthopedic injuries.

After conducting a

primary survey, the examiner should obtain an injury
history and observe and palpate the athlete for any
indications of more severe trauma.10,24

Special tests for

mental status of the athlete as well as postural control
and concussion related symptoms will provide objective
information that supports the clinical examination.24
The assessment tools available to all healthcare
providers, whether it concussion grading scales, paper and
pencil, or computer-based tests, should be used to evaluate
each domain of the injury.

These tests provide the highest

sensitivity and specificity of concussion assessments and
it also gives the healthcare provider the most information
to make an informed decision for return to play.24
Throughout the evaluation process the people administering
the assessment should be aware about the development,
presence, intensity, and return of concussion related
symptoms.8,10,24

Under no circumstances should an athlete

return-to-play if he or she reports a symptom that is
categorized under a concussion.13,24

Athletes playing with

lingering symptoms can result in SIS or PCS, which poses a
very serious situation.

In conclusion, management of and

90
return-to-play following a sports-related concussion should
involve a team approach, which includes educating the
athletes, parents, and coaches about the injury as well as
being on the same page as all of the other medical
personnel involved in the injury.

91

APPENDIX B
The Problem

92
The Problem

Statement of the Problem
Sports-related concussions are a major sports medicine
issue in today’s world of athletics.

There have been many

guidelines constructed to allow for better identification,
assessment, diagnosis, and management of return-to-play for
athletes sustaining this serious injury.

The tools used to

better assess and diagnose sports-related concussions range
from standard balance screening to computerized
neurological testing and there is no telling which is more
suited for healthcare providers.
Reports have shown concussion injuries in multiple
sports and the trend of this traumatic brain injury has
been increasing in occurrence over the past several years.2
There has been great attention given to the research of
this injury to form a better understanding in terms of
athletes’ health concerns.

Still, many concerns remain in

relation to the assessment and management of sports-related
concussions.
Therefore, the purpose of this study was to determine
the most commonly utilized method for concussion assessment
by ATs.

A survey was used to measure the most commonly

93
used method for assessment by those ATs, as per the NATA
Position Statement.

Definition of Terms
The following definitions are provided, for
clarification:
1)

Assessment of Concussion- A process of observation and

documentation of signs and symptoms in which the athlete is
experiencing once they have sustained a concussion.
2)

Certified Athletic Trainers (ATs)- health care

professionals certified by the Board of Certification who
specialize in preventing, recognizing, managing, and
rehabilitating injuries that result from physical
activity.38
3)

Concussion- Any trauma-induced alteration in mental

status that may or may not include loss of consciousness.7
4)

Return to Play- The process of an athlete returning to

full participation after cleared by the health care
provider.

94
Basic Assumptions
The following assumptions were made in regards to this
study:
1)

All survey questions were answered honestly,

correctly, and to the best of the ability of the athletic
trainer.
2)

The sample obtained for this research was a

representation of the NATA District 2 population.

Limitations of the Study
The following are possible limitations of this study:
1)

Subject contact information could contain incorrect

names or email addresses of athletic trainers.
2)

The subjects participating in the survey were

volunteers who represented enthusiastic individuals within
the athletic training population.
3)

Only certified athletic trainers within the NATA

District 2 were surveyed.

95
Significance of the Study
The sports-related concussion injuries are numerous
and can be very overwhelming at times for health care
providers.

Each athlete that sustains a concussion

deserves a thorough assessment and each health care
provider should have the knowledge and access to the
appropriate methods for concussion assessment as well as
the ability to determine when the athlete is to return-toplay.

The purpose of this study is to determine the most

utilized tool for assessment of sports-related concussions
by certified athletic trainers (ATs).
Sports-related concussions are very important and
serious injuries in the world of athletics and the proper
medical attention is necessary for each athlete who
sustains such an injury.

If these serious injuries are

assessed and evaluated promptly and properly by the
healthcare providers, then both the athletes and the AT,
coaches, teammates, and parents of the athlete would
greatly benefit.

ATs are just one of the many health care

providers who are critical aspects in the world of athletic
healthcare.

Having the correct knowledge and ability to

assess and make important decisions about return-to-play
after a concussion is sustained is key.

The AT can also

provide the athlete with the right concussion management

96
and progression to a safe return to participation of the
athlete’s sport.

Management of concussion injuries and

return-to-play following a concussion should involve a team
approach, which includes educating the athletes, parents,
and coaches about the injury as well as being informed as
all of the other medical personnel involved in the injury.

97

APPENDIX C
Additional Methods

98

APPENDIX C1
CONCUSSION GRADING SYSTEM SCALES

99
CONCUSSION GRADING SYSTEM SCALES

Grade/

Cantu

Level
1

2

Colorado Medical
Society

American Academy
of Neurology

No LOC;

No LOC;

Transient

posttraumatic

confusion; no

confusion; no

amnesia lasting

amnesia; RTP

LOC; symptoms &

< 30 min or

after 20 min

mental status

postconcussion

with normal exam abnormalities

s/s lasting < 24

resolve in < 15

hr

min

LOC lasting < 1

No LOC;

Transient

min or

confusion;

confusion; no

posttraumatic

amnesia; no RTP

LOC; symptoms &

amnesia lasting

that day

mental status

30 min-24 hr or

abnormalities

postconcussion

last > 15 min

s/s lasting > 24
hr but < 7 days

3

LOC lasting > 1

LOC; transport

Any LOC; brief

100
min or

to ER with full

(seconds) or

posttraumatic

neck injury

prolonged

amnesia lasting

precautions,

(minutes)

> 24 hr; or

neurosurgical

postconcussion

evaluation

s/s lasting > 7
days

101

APPENDIX C2
Concussion Testing as Utilized and Preferred by Certified
Athletic Trainers Survey

102

Cerebral Concussion Testing as Utilized and Preferred by
Certified Athletic Trainers Survey
Directions: Please answer all of the following questions as
honestly as possible. Thank you.
1.

2.

3.

Gender:
a.

Female

b.

Male

What is your highest educational level?
a.

Bachelor’s degree

b.

Master’s degree

c.

Doctoral degree

What state do you currently practice in?
a.

Pennsylvania

b.

New Jersey

c.

New York

d.

Delaware

4.
In addition to the ATC credential, please indicate
below all other professional credentials that you possess
(Please select all that apply):
a.

PT

b.

PTA

c.

PA

d.

MD

e.

OT

f.

OTA

g.

EMT

103
h.

RN

i.

Teacher Certification

j.

ACSM-HFS

k.

CSCS

l.

PES

m.

None

n.

Other ________________________ (please specify)

5.
How many years you have been working as a Certified
Athletic Trainer? ___________ years
6.

7.

What is your current primary position?
a.

Clinical

b.

Academic (Teacher/Professor)

c.

Research

d.

Administrative

e.

Student

f.

Other ________________________ (please specify)

What is your current employment setting?
a.

College/University

b.

Professional athletics

c.

High school

d.

Sports Medicine Clinic

e.

General Hospital setting

f.

Academic department

g.

Fitness Center

h.

Personal Trainer

i.

Corporate health (company)

104
j.

Other ________________________ (please specify)

8.
As per the NATA Concussion Position Statement, which
method is currently being used at your institution/job
site?
a.

Grading the concussion

b.

Deferring final grading until all symptoms have
resolved

c.

No grading, but using symptoms, neurocognitive
testing and postural stability testing.

9.
Which of the following concussion methods tools have
you utilized during your career (choose all that apply)?
a.

Standardized Assessment of Concussion (SAC)

b.

Balance Error Scoring System (BESS)

c.

ImPACT (Immediate Post Concussion Assessment and
Cognitive Testing)

d.

CogSport

e.

HeadMinder CRI (Concussion Resolution Index)

f.

Other _______________________________ (please
specify)

10. Are you the person responsible for making decisions
about what concussion method is utilized?
a.

Yes

b.

No

11. If you are not responsible for making decisions about
what concussion method is utilized, who is responsible?
a.

Team MD

b.

Athletic trainer

c.

Athletic Director

105
d.

Other _______________________________ (please
specify)

12. What primary method/tool do you typically utilize to
assess concussions?
a.

Grading Scale (ex. Cantu or Colorado)

b.

Pencil and paper (ex. SAC or BESS)

c.

Computer based Neurocogitive Testing (ex. ImPACT,
CogSport, or HeadMinder CRI)

13. What method/tool would you prefer to use when
assessing concussion injuries?
a.

Grading Scale (ex. Cantu or Colorado)

b.

Pencil and paper (ex. SAC or BESS)

c.

Computer based Neurocogitive Testing (ex. ImPACT,
CogSport, or HeadMinder CRI)

14.
How has the method influenced you to use the method
you use?
a.

Supported research

b.

Experience

c.

Cost

d.

Other _______________________________ (please
specify)

Approved by the California University of Pennsylvania IRB

106

Appendix C3
Institutional Review Board

107
Institutional Review Board
California University of Pennsylvania
Psychology Department LRC, Room 310
250 University Avenue
California, PA 15419
instreviewboard@cup.edu
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair

Dear Bethany,
Please consider this email as official notification that your proposal titled
“Cerebral Concussion Testing as Utilized and Preferred by Certified
Athletic Trainers in District 2” (Proposal #09-038) has been approved by the
California University of Pennsylvania Institutional Review Board as submitted.
The effective date of the approval is 01-28-2010 and the expiration date is
01-28-2011. These dates must appear on the consent form .
Please note that Federal Policy requires that you notify the IRB promptly regarding
any of the following:
(1) Any additions or changes in procedures you might wish for your study
(additions or changes must be approved by the IRB before they are
implemented)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are necessitated
by any events reported in (2).
(4) To continue your research beyond the approval expiration date of 01-282011 you must file additional information to be considered for
continuing review. Please contact instreviewboard@calu.edu

Please notify the Board when data collection is complete.
Regards,
Christine Gorby
IRB Graduate Assistant

108

Appendix C4
Subject Cover Letter

109
Date: Thursday, November 12, 2009
Dear Fellow Certified Athletic Trainer:
My name is Bethany Arbaugh and I am currently a graduate
student at California University of Pennsylvania pursing a
Master of Science in Athletic Training. Part of the
graduate study curriculum is to fulfill the thesis
requirement through conducting research; mine will be
survey research, and I am working with my Thesis Chair, Dr.
Carol Biddington to investigate my research question. The
primary purpose of this thesis study is to determine the
most utilized and preferred cerebral concussion assessment
and management tools in terms of diagnosis and return to
play decision making. This model will predict the usage of
different cerebral concussion testing tools based on what
is used and preferred by certified athletic trainers
(ATCs). If an effective study can be predicted it will
affect ATCs, which will enhance the future of cerebral
concussion testing used in the careers of athletic
trainers.
Certified athletic trainers within District 2 are being
asked to participate in this research survey however, your
participation is voluntary and you do have the right to
choose not to participate. You also have the right to
discontinue participation at any time during the survey
completion process at which time your data will be
discarded. The California University of Pennsylvania
(CalU) Institutional Review Board has reviewed and approved
this project. The approval is effective 01/28/2010 and
expires 01/28/2011.
All survey responses are anonymous and will be kept
confidential, and informed consent to use the data
collected will be assumed upon return of the survey.
Aggregate survey responses will be housed in a password
protected file on the CalU campus. Minimal risk is posed
by participating as a subject in this study. I ask that
you please take this survey at your earliest convenience.
The questionnaire will take approximately 15 minutes to
complete. If you have any questions regarding this
project, please feel free to contact the primary
researcher, Bethany Arbaugh at arb4954@calu.edu.
You can
also contact the faculty advisor for this research, Dr.
Carol Biddington, 724-938-4356, Biddington@calu.edu.
Thanks in advance for your participation. Please click the

110
following link to access the survey or copy the link and
paste it as a URL: http://www.surveymonkey.com/s/G5S3ZHF
Thank you for taking the time to take part in my thesis
research. I greatly appreciate your time and effort put
into this task.
Sincerely,
Bethany J. Arbaugh
Primary Researcher
California University of Pennsylvania
250 University Ave
California, PA 15419
610-914-1145
Arb4954@calu.edu

111

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ABSTRACT
Title:

SPORTS-RELATED CONCUSSION TESTING AS
UTILIZED BY CERTIFIED ATHLETIC TRAINERS IN
NATA DISTRICT 2

Researcher:

Bethany J. Arbaugh, ATC, PES

Advisor:

Dr. Carol Biddington

Date:

May 2010

Research Type: Master’s Thesis
Context:

Sports-related concussions are a major
sports medicine issue in the current medical
literature as well as popular media. There
have been many guidelines constructed to
allow for better identification, assessment,
diagnosis, and management of return-to-play
for athletes sustaining this serious injury.
The tools used to better assess and diagnose
sports-related concussions range from
standard balance screening to computerized
neurological testing and there is no telling
which is more suited for healthcare
providers.

Objective:

The purpose of this study was to determine
the most commonly utilized method for
concussion assessment by certified athletic
trainers (ATs).

Design:

Descriptive research design.

Setting:

Controlled setting.

Participants:

Certified athletic trainers (N=152), who
volunteered, within the NATA District 2 were
participants.

Interventions: Subjects were sent a survey asking
demographics, which included the following:
gender, years of experience as a certified
athletic trainer, credentials, current
occupation, and the level of education.
Additional items related to assessment and

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return-to-play decision making of sportsrelated concussion injuries were addressed.
The survey was designed to be completed in
20 minutes or less. The subjects then
completed the survey over the internet and
gave their consent by returning the survey
anonymously.
Main Outcome
Measures:

The ATs preference for utilizing one of the
three recommended concussion assessment
methods stated in the NATA position
statement.

Results:

The results showed that there was a
significant deviation from the hypothesized
values found. The most used concussion
assessment method was “no grading, but using
symptoms, neurocognitive testing and
postural stability testing” among the ATs in
District 2 of the NATA.

Conclusions:

Athletic trainers within District 2 most
commonly utilize the multiple method
approach to assess sports-related
concussion, not using a grading scale but
rather focusing attention on the athlete’s
recovery via symptoms, neurocognitive
testing, and postural-stability testing,
which is recommended by the NATA position
statement.

Word Count:

299