Continuing Education Practices of Athletic Trainer’s and
Confidence and Knowledge of Concussion Management

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
Zak M. Christie

Research Advisor, Dr. Linda Platt Meyer
California, Pennsylvania
2013

ii

iii

ACKNOWLEDGEMENTS
I would like to take this time to identify individuals
whom have helped me throughout this research process.
Without them, I would not have been able to complete my
research.
My family (Mom, Dad, Papou, Grandma, Dan, Cody and
Kristina) without a doubt is the largest support system I
have. Without their encouragement I would not have believed
in myself enough to finish, words cannot describe my
gratitude and love.
I would also like to thank my committee members for
the time and feedback that they have given me. Dr. Mike
Meyer and Dr. Will Biddington provided me with incredible
wisdom, and It has allowed me to be proud of this document.
I want to especially thank Dr. Linda Platt Meyer,
she has been an inspiration to work with, and the best
chair/ mentor a graduate student could hope for. If
anything I will look back at this research process with
fond memories of her encouragement and direction. It fills
me with encouragement that there are AT’s like my committee
still promoting our profession.

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

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

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

. . . . . . . . . . . . . . iv

. . . . . . . . . . . . . . . vi

. . . . . . . . . . . . . . . .

1

. . . . . . . . . . . . . . . . . .

4

Research Design

. . . . . . . . . . . . . .

4

. . . . . . . . . . . . . . . . .

5

Preliminary Research. . . . . . . . . . . . .

5

Instruments . . . . . . . . . . . . . . . .

6

Procedures

7

Subjects

. . . . . . . . . . . . . . . .

Hypothesis . . . . .

. . . . . . . .

8

. . . . . . . . . . . . . . .

8

. . . . . . . . . . . . . . . . . .

9

Demographic Data . . . . . . . . . . . . . .

9

Data Analysis
RESULTS

Hypothesis Testing

. .

. .

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

Additional Findings . . . . . . . . . . . . . 16
DISCUSSION . . . . . . . . . . . . . . . . . 17
Discussion of Results . . . . . . . . . . . . 17
Conclusions . . . . . . . . . . . . . . . . 21
Recommendations. . . . . . . . . . . . . . . 21

v
REFERENCES . . . . . . . . . . . . . . . . . 23
APPENDICES . . . . . . . . . . . . . . . . . 27
APPENDIX A: Review of Literature

. . . . . . . . 28

Introduction . . . . . . . . . . . . . . . . 29
Etiology

. . . . . . . . . . . . . . . . . 30

Validity Testing . . . . . . . . . . . . . . 33
Management Styles . . . . . . . . . . . . . . 42
Athletic Training Education . . . . . . . . . . 44
Measuring Confidence . . . . . . . . . . . . . 47
Summary . . . . . . . . . . . . . . . . . . 49
APPENDIX B: The Problem . . . . . . . . . . . . 51
Statement of the Problem . . . . . . . . . . . 52
Definition of Terms . . . . . . . . . . . . . 54
Basic Assumptions . . . . . . . . . . . . . . 54
Limitations of the Study . . . . . . . . . . . 55
Significance of the Study

. . . . . . . . . . 55

APPENDIX C: Additional Methods .

. . . . . . . . 57

IRB: California University of Pennsylvania (C1) . . 58
Letter to Panel of Experts (C2) . . . . .

. . . 72

Concussion Knowledge and Confidence Survey (C3) . . 74
Cover Letter (C4)

. . . . . . . . . . . . . 85

References . . . . . . . . . . . . . . . . . 88
ABSTRACT

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

vi
LIST OF TABLES
Table

Title

Page

1

Range of Age . . .

. .

2

Gender. . .

. . . . . . .

3

Years Working as an AT . .

. . .

. .

. . . . . .
.

10

. .

10

4

Work Setting . . . . . . . . . . . . .

10

5

NATA District

11

6

Level of Education

. . . . . . . . . .

11

7

Credential(s) Held

. . . . . . . . . .

12

8

Independent
Statistics:
Independent
Statistics:
Independent
Statistics:
Independent
Statistics:

. .

. .

. .

9

.

. . . . . . . . . . . .

t-test group
Knowledge .
t-test group
Knowledge .
t-test group
Confidence .
t-test group
Confidence .

. . . . . .

. . 14

. . . . . .

. . 14

. . . . . .

. . 15

. . . . . .

. . 15

12

Confidence Measurement 1 . . . . . .

. . 15

13

Confidence Measurement 2 . . . . . .

. . 15

14

Confidence Measurement 3 . . . . . .

. . 16

15

mTBI vs. Concussion . . . . . . . . . . 16

9
10
11

1

INTRODUCTION

The increased worth that the public has put on
athletics has increased the intensity of the games along
with the risks that accompanies them. One of these risks is
concussion, a form of brain injury. The Centers for Disease
Control (CDC) reports that over 1.7 million people suffer
from concussions annually.1 The high rate of occurrence
brings attention to the people that are on the front line
of concussion evaluation, management and treatment. The
Athletic Trainer (AT) is the front line health care
professional. Athletic training education must make ATs
confident in situations when they are placed in stressful
situations when dealing with concussions.
There are multiple diagnostic tools that ATs can use
to help in their recognition and management of concussion.
These tools range from the traditional models2,3,4,5 to the
newer computer-based neurocognitive testing which allows
for quantitative variables.

6,7,8,9,10,11,12

These tools can

contribute to the ATs’ confidence level in assessing
severity and making return-to-play decisions.13,14

2
Because there is such a high rate of occurrence of
concussions in athletics, it is imperative that ATs are
confident in their own abilities. It is also equally
important that ATs be familiar and up-to-date with the most
recent concussion protocols. The most current and highly
respected concussion protocol is addressed in the 2009
Zurich Consensus Statement on concussion in sport.14
Continuing education awareness stands as one of the
strongest tools ATs have in regards to managing concussions
properly.12-18 It is crucial that all ATs are aware and
practicing current concussion management.
Another important and overlooked aspect of athletic
training is the level of confidence that practitioners
have. Building confidence is an important aspect of
clinical education. Progressing students to a confident
level of medical practice should be one of the main goals
of the academic institutions. A study conducted by
Hecimvich and Volet19 examined the progress of chiropractic
students’ confidence before and after their clinical
internships. After their clinical internships, both patient
communication and clinical skills increased significantly.
The study highlighted the contributing factors in building
confidence and found that taking a proactive, hands-on
approach is the most beneficial. Confidence typically

3
increases with experience, though it is still important for
newly-certified ATs to portray confidence and feel certain
when dealing with concussions in the field.
The purpose of this study is to discuss the continuing
education practices of AT’s along with their concussion
management confidence and knowledge. This study
additionally will evaluate current knowledge of concussion
protocols. By surveying ATs throughout the ten districts of
the National Athletic Trainers’ Association (NATA), a
better understanding can be made of what educational
factors increase ATs' confidence in regards to concussion.
From these conclusions, possible changes in athletic
training continuing education programs can be adapted to
improve confidence levels when managing concussion. This
segment of the study will also allow the researcher to
spot-check the profession for up-to-date practice
techniques for concussion management.

4

METHODS

The purpose of this is to discuss the continuing
education practices of AT’s along with their concussion
management confidence and knowledge. Additionally, this
study evaluates current knowledge of concussion protocols.
This section includes the following sections: Research
Design, Subjects, Instruments, Procedure, and Data
Analysis.

Research Design

A descriptive design was used for this study.

The

dependent variable is the confidence and knowledge of ATs
in regards to concussion management. The independent
variable was continued education participation that ATs
have with regards to concussion.

5

Subjects

One-thousand ATs were asked to volunteer by taking a
survey for this study. Subjects (N=1000) were randomly
selected from the ten districts through the NATA database.
Subjects implied informed consent with the completion and
return of the survey. Participation in the study was
voluntary based upon completion of the survey. The study
was approved by the Institutional Review Board (Appendix
C1) at California University of Pennsylvania prior to
launching the survey.

Preliminary Research

A panel of experts was organized before any research
was conducted (Appendix C2). The panel consisted of ATs
with experience and knowledge of concussions and survey
research construction. The panel members were sent the
Concussion Knowledge Survey and instructions on their
responsibilities regarding the survey. The panel members
reviewed the survey instrument and cover letter. They added
to the content validity and made recommendations for
improvement. After reviewing the survey, the panel members

6
provided critiques and changes that were reviewed for
potential revision to the instrument. Necessary changes
were made to the survey based on critiques by a panel of
experts.

Instruments

An original survey was created and entitled
“Concussion Knowledge and Confidence Survey.” The survey is
found in Appendix C3. The survey consists of questions
regarding overall confidence level in concussion
evaluation, evaluation techniques, managing tools, any
deficiencies perceived by the AT, and utilized return-toplay protocols. The data was automatically collected by
SurveyMonkey® and placed into spreadsheet format for the
researcher to utilize in analysis. The survey consisted of
36 questions and required ten minutes to complete.
Variables were measured by exploring the effects of
educational experiences and current knowledge ATs have on
concussion. A cover letter explaining the risks involved,
informed consent and instructions of the confidence and
knowledge study also accompanied the survey (Appendix C4).

7

Procedures

A cover letter with a link to the concussion
confidence survey was distributed via e-mail to a random
sample of ATs by the NATA via SurveyMonkey.com, a web-based
survey program. The researcher allowed three weeks for the
ATs to complete the survey. Once a week, during the three
weeks, a follow up e-mail was sent to the survey subjects
explaining the study and providing a link to the survey.
This e-mail was to remind the subjects the survey was still
open and able to be completed. The e-mail also stated if
the subject had already taken the survey, they do not need
to take it again. Once the surveys were completed, the
answers were submitted back through SurveyMonkey.com. The
web server program automatically organized, calculated, and
placed all data in an Excel spreadsheet for import to SPSS
18.0. Data analysis was then performed on the survey
results after the three week submission period had passed.

8

Hypothesis

The following hypothesis is based on previous research
and the review of the literature.
1. There will be a difference between participants who
identified themselves as likely to search for peerreviewed literature on concussion management and those
participants who did not identify themselves in
seeking out new literature for concussion management
knowledge.

Data Analysis

All data will be analyzed by SPSS version 16.0
for windows at an α level of 0.05.

The research hypothesis

was analyzed using t-test to measure for means.

9

RESULTS

The purpose of this study is to discuss the continuing
education practices of AT’s along with their concussion
management confidence and knowledge. By surveying a random
sample of ATs through the NATA, the profession can identify
possible trends and/ or deficiencies in regards to
concussion management.

Demographic Information
One thousand Athletic Trainers were asked to volunteer
to take an original survey for this study. Out of the 1,000
Athletic Trainers, 16.9% (N=169) responded to the survey.
Table 1 represents the ages of the ATs surveyed.
Table 1. Range of age
Age
18-22
23-27
28-32
33-37
38-42
43-47
48-52
53-57
>57

Frequency

Percentage

4
45
32
22
20
14
13
6
13

2.3
26.6
18.9
13.0
11.8
8.2
7.6
3.5
7.6

10
Table 2 represents the gender of the surveyed ATs.
Table 2. Gender
Gender
Female
Male

Frequency
93
76

Percentage
55.0
45.0

Table 3 represents the range number of years practicing as
a Certified Athletic trainer in this study.
Table 3 Years working as an AT.
Years
Frequency
0-1
6
1-5
48
5-10
27
10-15
29
20-25
28
>25
31

Percentage
3.6
28.4
16.0
17.2
16.6
18.3

Table 4 represents the current work setting of the surveyed
ATs in this study.
Table 4 Work Setting
Setting
College/
University
Hospital/
Clinical
Occupational/
Industrial
Military
Performing Arts
Professional Sports
Public Safety
Clinic/
Secondary School
Hospital/
Secondary School
Other

Frequency
60

Percentage
35.5

14

8.3

4

2.4

0
0
4
0

0.0
0.0
2.4
0.0

43

25.4

9
35

5.3
20.7

11
Table 5 represents the NATA district that the surveyed AT
is currently working .
Table 5. NATA district
District
1
2
3
4
5
6
7
8
9
10

Frequency
16
31
22
36
7
9
9
12
19
8

Percentage
9.5
18.3
13.0
21.3
4.1
5.3
5.3
7.1
11.2
4.7

Table 6 represents the highest level of education of the
surveyed AT.
Table 6. Level of education
Degree
Frequency
Bachelors
49
Masters
108
Doctorate
11
Other
1

Percentage
29.0
63.9
6.5
0.6

12
Table 7 represents the credentials which the AT surveyed
holds.
Table 7. Credential(s) held
Credential
Frequency
ATC
165
EMT
9
PA-C
0
RN
0
LPN
0
Nurse Practitioner
0
LMT
2
DC
0
DPT
2
CSCS
16
PES
9
Not Available
0
Other
34

Percentage
97.6
5.3
0
0
0
0
1.2
0
1.2
9.5
5.3
0
20.1

13

Hypothesis Testing

The following hypothesis was tested in this study. The
hypothesis was tested with a level of significance set at
an α ≤ 0.05. A t-test was used for statistical measurement.
Hypothesis:

There will be a difference between

participants who identified themselves as likely to search
for peer-reviewed literature on concussion management and
those participants who did not identify themselves in
seeking out new literature for concussion management
knowledge.

An independent test was calculated comparing

the mean score of participants who identified themselves as
likely to search for peer-reviewed literature on concussion
management to the mean score of those participants who did
not identify themselves in seeking out new literature.
Conclusion: In regards to concussion management
knowledge, no significant difference was found ((t147 = .341, p>.05). The mean of the likely group (8.633 ± 1.32)
was not significantly different from the mean of the nonlikely group (8.550 ± 1.29). Therefore, there is no
difference between the knowledge of those individuals who
are likely to seek out peer reviewed literature and those

14
who do not seek out peer reviewed literature. This is
represented by Tables 8 and 9 below.

Table 8. Independent t-test group statistics: Knowledge
Group
Number of
Mean
SD
Not
Likely
Likely

40

8.55

1.29

109

8.63

1.32

Table 9. Independent t-test group statistics: Knowledge
Classification
t
df
Sig.
Percentage(Equal
Variances
assumed)

-.341

147.0

.891

No significant difference was found in regards to
concussion management confidence (t(152)= .328, p>.05). The
mean of the likely group (M= 11.50, SD= .983) was not
significantly different from the mean of the non-likely
group (M= 11.56, SD= .838) in regards to concussion
management knowledge. Therefore, there is no difference
between the confidence of those individuals who are likely
to seek out peer reviewed literature and those who do not
seek out peer reviewed literature. This is represented by
Tables 10 and 11 below.

15
Table 10.Independent t-test group statistics: Confidence
Group
Number of
Mean
Std. Error
Subjects
(SD)
Mean
Not
41
11.56
.130
Likely
(.838)
Likely
113
11.50
.092
(.983)

Table 11. Independent t-test group statistics: Confidence
Classification
t
df
Sig.
Percentage(Equal
Variances
assumed)

.328

152.0

.617

Confidence in the subjects was determined by a total
of three questions, using a four point likert scale. These
results are represented by Tables 12, 13, and 14 below.
Table 12. How confident are you in recognizing the signs
and symptoms of concussion?
District
Frequency
Percentage
Very Confident
139
89.1
Somewhat Confident
15
9.6
Not Confident
0
0.0
Very Unconfident
2
1.3
Table 13. How confident are you in describing the
mechanism(s) of injury for concussion?
District
Frequency
Percentage
Very Confident
132
84.6
Somewhat Confident
24
15.4
Not Confident
0
0.0
Very Unconfident
0
0.0

16
Table 14. How confident are you in preforming a sideline
evaluation of concussion?
District
Frequency
Percentage
Very Confident
128
82.1
Somewhat Confident
26
16.7
Not Confident
1
0.6
Very Unconfident
1
0.6

Additional Findings

Findings that were also noteworthy to the study were
found in the knowledge assessment portion of the survey.
The survey asked the ATs if the terms “mild traumatic brain
injury (mTBI)” and “concussion” were interchangeable terms.
This resulted in n=152 responses, of these responses 68.4%
answered that they were interchangeable terms. This is
represented by Tables 12 below.
Table 15. mTBI vs. Concussion
Response
Frequency
True
103
False
46

Percentage
68.4
31.6

Another important finding involved the current
reference that the surveyed AT used as current concussion
management guidelines. This resulted in N=152 responses. In
all, 52.6% (n=80) reported that they use the NATA position

17
statements as their current concussion management
guidelines. Only 24.3% (n=37) reported that they use the
Zurich Consensus Statement of Concussion in Sport. The
Zurich Consensus Statement of Concussion is the most
current guideline in concussion management.

DISCUSSION

The following section is divided into three
subsections: Discussion of Results, Conclusions, and
Recommendations.

Discussion of Results

This study focused on continuing education awareness
and its effect on concussion management confidence and
knowledge. Upon research, there were no significant
findings when testing the hypothesis. The majority of the
knowledge questions were answered correctly. However, some
additional findings suggest that there are improvements to
be made in regards to concussion knowledge.

18
The hypothesis is: that there will be a difference
between participants who identified themselves as likely to
search for peer-reviewed literature on concussion
management and those participants who did not identify
themselves in seeking out new literature for concussion
management knowledge. It was thought that the subject group
identified as “likely to go find peer-reviewed literature”
to score higher than the group identified as “not likely to
find peer-reviewed literature”. There was no previous
literature in reference to concussion management knowledge
and confidence and its relation to continuing education
awareness in the athletic training profession. Based on the
researcher’s own experiences and interaction with peers, it
was thought that the ATs who self-identified as “likely to
go find peer-reviewed literature” to have higher concussion
management confidence and knowledge then the “not likely”
group. However, the difference between the groups was not
significant and does not support this hypothesis.
Throughout the research, there were some additional
findings that are worth discussion. Research conducted by
Scorza, Raleigh et al20 was reaffirmed by this study. During
their study, they stated that one of the most common
symptoms of concussion is headache, and that both somatic
and cognitive systems can be affected. This survey

19
identified that 100.0% (n=152) of ATs identified dizziness
as a common symptom, along with 99.3% (n=151) reporting
headache and balance issues as a common symptom.
Electronic testing prevalence was also assessed in
this study. Of the subjects, 69.2% (n=108) reported that
they use electronic based concussion testing in their
concussion management practice. Stiller-Ostrowski17 also
investigated the prevalence of electronic baseline testing;
they also found that majority ATs used electronic based
tools in the management of concussion. In regards to the
electronic software, this study revealed that 80.2%(n=101)
of the subjects used the ImPACT™ test as their electronic
testing software.
Eckner and Kutcher

23

state in their study that signs

and symptoms of concussion do not necessarily present
themselves at the time of the injury. In fact, main signs
and symptoms might be delayed. This survey affirmed that
the general AT population is up-to-date in regards to signs
and symptoms possibly being delayed. When asked if signs
and symptoms of concussion always present themselves after
the mechanism of injury, 98.0% (n=149) responded correctly
that the signs and symptoms do not always present after the
mechanism of injury.

20
This research has shown that athletic training
professionals have a competent level of concussion
knowledge when compared to the Zurich Consensus Statement
on concussion in sport14 the current gold-standard for
concussion protocol. Of the subjects, 100.0% (n=152)
indicated that special considerations should be taken when
treating children or adolescents (under 18 years old) who
have sustained a concussion. Of the subjects 86.2% (n=131)
correctly answered false when asked if there is any
equipment suggested by evidence-based research that can
prevent concussion injuries. When asked about the subjects
return to play protocol, 94.1% (n=143) correctly responded
that it was best described as: “a step-wise progression
that gradually increases the patient’s activity per every
24 hours.” It was also found that 93.3% (n=140) of ATs
correctly take 24 hours between steps in their return to
play protocol.
The study did find some deficiencies in regards to
concussion management knowledge. A large amount of the
subjects answered incorrectly 68.4% (n=104) that mTBI and
concussion are interchangeable terms. Harmon, Kimberly et
al.21 states that : Concussions have also been referred to as
mTBI While all concussions are mTBIs, not all mTBIs are
concussions. Concussions are a subset of mild traumatic

21
brain injury on the less severe end of the brain injury
spectrum and are generally self-limited in duration and
resolution. It was also found that 52.6% (n=80) use the
NATA position statements as their current concussion
management reference.

Conclusions

The results of this study do not support the
hypothesis, though they do affirm the results of previous
studies identified in the literature review. The overall
results indicated that ATs have a solid understanding of
concussion and the many tools to manage this injury. Based
on the results of this study, it may be suggested that the
NATA should update its concussion management guidelines to
include the most recent concussion management protocol; and
in this protocol to identify the difference between
concussion and mTBI.

Recommendations

The purpose of this study is to discuss the continuing
education practices of AT’s along with their concussion
management confidence and knowledge. After reviewing the

22
results, recommendations for future research can be made.
The first recommendation that can be made is to increase
the sample size; a higher response rate may allow for a
better representation of the athletic training profession
across the nation. Another recommendation would be to use
professional memberships, which was identified as the most
beneficial form of continuing education opportunities in
regards to concussion management (71.6%, N=111). This could
be used as a way to update the athletic training population
on the most current concussion guidelines. The last
recommendation would be to identify the difference between
mTBI and concussion in the most recent concussion
management guidelines.

23
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Guskiewicz K, Bruce S, Cantu R, et al. National
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14.

McCrory P, Meeuwisse W, Johnson K, et al. Consensus
Statement on Concussion in Sport: The 3rd
International Conference on Concussion in Sport Held
in Zurich, November 2008. J Athl Train. [serial
online]. July 2009;44(4):434-444. Available from:
SPORTDiscus with Full Text, Ipswich, MA. Accessed June
22, 2012.

15.

Noteaert AJ, Guskiewicz KM. Current Trends in Athletic
Training Practice for Concussion Assessment and
Management. J Athl Train 2005;40(4):320-325.

16.

Hunt TN, Trombley A. Physician Management of SportRelated Concussions at the Collegiate Level. Atshc
2010;2(5):227-234.

17.

Covassin T, Elbin R, Kontos AP, et al. Immediate PostConcussion Assessment and Cognitive Testing (ImPACT)
Practices of Sports Medicine Professionals. J Athl
Train 2009;44(6):639-644.

25
18.

McLeod TC. Register-Mihalik JK. Clinical Outcomes
Assessment for the Management of Sport-Related
Concussion. J SPORT REHABIL 2011;20(1):46-60.

19.

Hecimovich M, Volet S. Tracing the evolution of
chiropractic students' confidence in clinical and
patient communication skills during a clinical
internship: a multi-methods study.BMC Medical
Education.June 2012;19;12:42.

20.

Scorza KA, Raleigh MG, O’Connor FG. Current Concepts
in Concussion: Evaluation and Management. American
Family Physician. 2012;85(2):123-132.

21.

Harmon KG, Drezner J, Gammons M, et al. American
Medical Society for Sports Medicine Position
Statement: Concussion in Sport. Clin J Sport Med
2013;(23):1-18.

22. Martinez DE. Bloodless Concussion: The Misunderstood
Injury. J Am Chiropractic Assoc 2011;(7):16-36.
23.

Pelletier J. Sports injuries in contact sports:
concussion and spinal injuries (invited presentation);
2005 Aug 4l Ottawa, Canada. Available from:
jcp@ca.inter.net.

24.

Eckner JT, Kutcher JS. Concussion Symptom Scales and
Sideline Assessment Tools: A Critical Literature
Update. ACSM 2010;9(1):8-15.

25.

Reddy CC ,Collins MW. Sports Concussion: Management
and Predictors of Outcome. ACSM 2009;8(1):10-15.

26.

Purcell L, Carson J. Sport-Related Concussion in
Pediatric Athletes. CLIN PEDIATR 2008;47(2):106-113.

27.

DeKosky ST, Ikonomovic MD, Gandy S. Traumatic brain
injury—football, warfare, and long-term effects. N
Engl J Med. 2010;363(14):1293-1296.

28.

Piland SG, Ferrara MS, Macciocchi SN, et al.
Investigation of Baseiine Seif-Report Concussion
Symptom Scores.J Athl Train 2010;45(3):273-278.

26
29.

Majerske CW, Mihalik JP, Ren D, et al. Concussion in
Sports: Postconcussive Activity Levels, Symptoms, and
Neurocognitive Performance. J Athl Train
2008;43(3):265-274.

30.

Mailer BJ, McLeod TC, Bay RC. Healthy Youth Are
Reliable in Reporting Symptoms on a Graded Symptom
Scale. J SPORT REHABIL 2008;17(1):11-20.

31.

Fox ZG, Mihalik JP, Blackburn T, et al. Return of
Postural Control to Baseline After Anaerobic and
Aerobic Exercise Protocols. J Athl Train 2OO8;43(5):456463.

32.

Broglio SP, Zhu W, Sopiarz K, et al. Generalizability
Theory Analysis of Balance Error Scoring System
Reliability in Healthy Young Adults. J Athl Train
2009;44(5):497-502.

33.

NATA ATEP contempencies (2006) National Athletic
Trainers’ Association (NATA). Athletic Training
Educational Competencies.4th ed. Dallas,TX:NATA; 2006.

34.

Covassin T, Elbin R, Stiller-Ostrowski SL. Current
Sport-Related Concussion Teaching and Clinical
Practices of Sports Medicine Professionals. J Athl
Train 2005;44(4):400-404.

35.

Hankemeier DA, Van Lunen BL. Approved Cljnical
Instructors' Perspectives on Implementation Strategies
in Evidence-Based Practice for Athletic Training
Students. J Athl Train 2011:46(6):655-664.

36.

Manspeaker S, Lunen BV. Overcoming Barriers to
Implementation of Evidence-Based Practice Concepts In
Athletic Training Education: Perceptions of Select
Educators. J Athl Train 2011;46(5);514-522.

37.

Chiang YZ, Tan KT, Chiang YN, et al. Evaluation of
educational methods in dermatology and confidence
levels: a national survey of UK medical students. INT
J DERMATOL 2011;50(2):198-202.

27

APPENDICES

28

APPENDIX A
Review of Literature

29

REVIEW OF LITERATURE
Appendix A:

Review of Literature

Concussion awareness and its education, has progressed
exponentially throughout the past decade. ATs practice
evidence-based medicine. This method of practice provides
the athlete/patient with the most current and effective
care. Concussion has had numerous evaluative tools created
to properly evaluate this potentially life-altering injury.
Newer methods are used to manage concussion, and it is up
to the practitioner to be aware of new strategies. Many of
these strategies are highlighted in consensus statments13,14
along with other continuing education opportunities.
It is crucial that ATs have experience and are
confident handling these injuries along with utilizing the
most recent management strategies. The purpose of this
study is to discuss the continuing education practices of
AT’s along with their concussion management confidence and
knowledge. The following sections that highlight this
information include (1) Etiology, (2) Validity of
Assessment Models, (3) Management of Concussion, (4)

30
Athletic Training Education Styles, and (5) Measuring
Confidence.

Etiology of Concussion

The awareness of concussion has been heightened in the
sports community and the general population greatly in the
past few decades with a rapid acceleration of concussionrelated injuries over the last few years. The accompanying
attention is concern; concern from parents, health care
practitioners, and those athletes whom are at risk of a
potentially fatal injury or one that can cause lifealtering dysfunction. As certified and licensed health care
professionals, it is the job of ATs to be proactive on the
treatment and management of this injury. However, to
properly treat an injury, one must understand the injury.
The Center for Disease Control (CDC) reports that
over 1.7 million people suffer from concussions annually.1
This is far more common than many would assume. As it is
common knowledge, concussions are injuries to the head.
Concussions are simply described as a disturbance in
brain function from direct or indirect force to the head.20
This injury is described as a functional injury, rather
than a structural injury and results from sheer stress to

31
the brain tissue caused by rotational or angular
forces.20,23,23 It is a common misconception that the subject
whom has sustained a concussion must have been struck
directly in the head. Martinez also describes denial as a
possible effect of concussion, making it imperative that
the practitioner be aware of multiple signs and symptoms22.
Pelletier23 defines concussion as a complex neuropathophysiological process affecting the brain, induced by
traumatic biomechanical forces, which include a traumatic
alteration in brain function that is manifested by an
alteration in awareness of consciousness. These forces
cause injuries to the subcortical white matter that include
shearing or diffuse axonal injury that may occur with or
without a focal injury. This is where many individuals make
light of this injury, there is no necessary impact that
must happen for the athlete to sustain a concussion.
Determining whether a patient has suffered a
concussion often presents the practitioner with
difficulties. This is because no two concussions are the
same,24,25 each concussion is unique, and many concussions do
not present themselves at the time of the injury. Rather,
their signs and symptoms are delayed24. Concussions have a
wide variety of signs and symptoms. Scorza, Raleigh, et al20
describe headache as the most common symptom of concussion,

32
although there are a variety of clinical domains (e.g.,
somatic, cognitive, affective) that can be affected. As
practitioners who rely on the patient to describe his/her
signs and symptoms, it is important to be aware of all the
possible effects of this injury.
The classification of concussion based on severity
remains a challenge because of problems with instruments
and testers, as well as the likelihood that the injured
will deny the injury24.
Age groups and concussions have become an increasingly
popular topic. Athletics has progressed to becoming more
aggressive at younger ages, which in turn makes younger
athletes more susceptible to injury. Purcell and Carson26
came to the conclusion that sports-related concussions
occur most frequently in the 10-14 year age group. DeKosky,
Ikonomovic, et al27 describe that there is an increase in
the accumulation of proteins related to neurodegeneration
caused by concussion, and it is occurring at younger ages,
with force previously thought to be irrelevant to the
recovery/incident of the injury.

33

Validity of Assessment Models

Throughout the history of sports medicine, there have
been dramatic changes in the way head injuries are treated.
The more progress as a profession, the more are capable to
address and appropriately evaluate diagnostic skills.
Practicing evidence-based medicine has allowed ATs to be on
top of the most recent and effective concussion assessment
models. The following sub-sections address the different
type of assessment models, and their reliability when
addressing concussions.

Computer-Based Assessment

In sports medicine practice, it is becoming more
common to use electronic based concussion testing as an
assessment tool. These tests specifically allow ATs to make
precise, quantifiable decisions when it pertains to a
concussion. Eckner, Kutcher, and Richardson6 conducted a
reliability study which compared manual reaction times
versus the reaction time component of CogState

34
Sport(version 5.6.4) computerized neuropsychological test.
The reliability study revealed that manual reaction time
testing when used for baseline protocol is a reliable means
of measurement when compared to computerized testing. The
manual testing methods included using the weighted stick
drop method as a measure of reaction time.

Manual testing

should be used in conjunction with computerized testing for
a multifaceted approach.6,9 However, computerized testing
reveals more precise measurements.6,10
Other studies also look into how precise the
computerized neurocognitive testing is, and whether it
should be used more frequently as a diagnostic tool. A
study conducted by Thomas, Collins, Saladino, et al10
examined the detective nature of the Immediate PostConcussion Assessment and Cognitive Testing (ImPACT™) taken
immediately (12 hours) after the injury. The ImPACT™ is an
electronic based neurocognitive assessment tool. Results
were then compared 3 to 10 days after the injury. This
study aimed to find if the ImPACT™ could detect differences
in head injury severity that clinical grading scales could
not detect. Results suggested that computerized testing
detected deficiencies that the clinical grading scale could
not, and could potentially be used as a tool to determine
the recovery time of the patient10.

35
As previously mentioned, health care providers rely on
the patient to report his/her signs and symptoms. However,
when the athlete reports he/she is asymptomatic, there are
times where neurocognitive deficiencies might be present.
Broglio, Macciocchi, and Ferrara12 conducted a study using
the ImPACT™ test in regards to identifying deficiencies in
athletes that reported they were asymptomatic.

The ImPACT™

test was administered to all athletes when symptomatic, and
when symptoms were reportedly resolved.

Results showed

there were deficiencies in at least one ImPACT™ variable
when the athlete stated he/she was asymptomatic. The
research suggests that using only symptom scores as the
return to play protocol is not advised and that a
multifaceted approach to concussion assessment is most
appropriate.
The ImPACT™ test is one of the more popular used
electronic concussion assessment tools. Allen and Gfeller7
used a clinical study consisting of 100 undergraduate
students from a small midwestern university to test the
validity of the ImPACT™ test. The ImPACT™ test was compared
to other traditional tests, results of the study revealed
that both traditional tests along with the computerized
ImPACT™ had overlapping results, and should be used in
conjunction with one another. Other computer-based

36
concussion assessment tools are being used: such as the
Concussion Resolution Index(CRI). Recent literature has
compared the CRI to the more popular ImPACT™ test. Results
have found that the tests are comparable to one another in
terms of reliability; however chronic neurocognitive
decrements from sport concussion may be subtle and
undetectable by either of these two assessment techniques11.
The ImPACT™ test is not the only computer-based
concussion assessment tool which is being used. Broglio,
Ferrara, Macciocchi, Baumgartner, and Elliott8 also examined
test/retest validity in computerized testing. The authors
conducted their subjects to complete the ImPACT™,
Concussion Sentinel and Head Minder Concussion tests on
three separate days. From their results, neurocognitive
assessments have been shown to be sensitive to the
consequences of concussion; and therefore, computerized
testing has many practical advantages in athletic settings.
The authors did warn practitioners to be cautious and to
approach concussions with a conservative approach, placing
greater focus on indexes producing higher reliability
scores.
The question of taking a computer-based assessment
will result in a significant change of scores still
remains. Brown, Guskiewicz, and Bieiberg9 investigated

37
possible trends due to gender, SAT scores and sport when
evaluating an athlete for neuropsychological testing.
Results concluded that computerized neuropsychological
tests could possibly be affected by some of the previously
mentioned factors.

Traditional Concussion Assessment

Traditional concussion assessments include those
assessments that rely on the patient's reported signs and
symptoms, these tests are generally administered via a
symptom score test or another method which does not heavily
revolve around a computer. Day, Hanson and Reding

2

specifically used the traditional Concussion Symptom
Assessment Scale (CSAS) along with the electronic
Concussion Resolution Index (CRI), to determine if they
were proper indicators of neurocognitive deficiency after
the patient reported no signs/symptoms. Both tests were
used in conjunction with one another for baseline testing.
This study showed that 35% of the athletes continued to
show neurocognitive deficiencies when reporting no signs or
symptoms.

38
Other traditional tools were also examined; the
Standardized Assessment of Concussion (SAC) was questioned
for reliability as a baseline tool. SAC testing proved to
hold poor reliability, and proved too simplistic for the
76% of the subjects. Ragan, Herrmann, Kang, and Mack3
concluded that the SAC test might not be the best for
cognitive testing, which diminishes the tests’ reliability
when used for baseline testing.
Not all traditional tests examine only patient signs
and symptoms. Beaumont et al5 found that athletes with a
history of concussion had altered scores in baseline
balance testing. Methods included using a force platform to
access center of pressure (COP) displacement, the subject
was then asked to perform rapid alternating movements.
Results revealed lower scores in those subjects who
sustained a concussion. The authors encourage practitioners
to acknowledge that baselines will vary over a period of
time.
The non-word repetition test (NWR) uses a method
which is described as a test that requires participants to
continuously repeat a group of chosen “non-words” aloud.
The test aims to measure the phonological loop, which
during a concussion can be impaired, therefore determining
the severity of the concussion. A total 166 concussions and

39
uninjured participants were administered the NWR test. Out
of these 166 subjects, 107 participants were included (46
concussions and 61 uninjured). Two studies were
administered to the group of subjects. The first group was
given the NWR along with the Rapid Screen of Concussion
(RSC) test. The second test administered the NWR along with
the Hopkins Verbal Learning Test. The NWR was found to be
reliable in regards to sub-vocal rehearsal speed and was to
the acute effects of concussion, thus being an effective
indicator in the subtle defects concussion has on patients.4

Baseline

Baseline testing is one of the most important factors
when managing concussions. The nature of the injury makes
it difficult to determine proper return-to-play decisions.
This is where baseline testing bridges the gap between
uncertainty and safe decision making. However, it is
advised for health care providers to be cautious when
relying on baseline testing which has been proctored over a
substantial period of time due to the changing nature of
the results.
An investigative study constructed by Piland, Ferrara,
et al.28 evaluates the influence that history of concussion,

40
sex, physical illness and acute fatigue has on selfreported baseline concussion testing. A total of six
National Collegiate Athletic Association institutions were
used, along with 1,065 collegiate student-athletes. Results
revealed that student-athletes with previous concussion
history, fatigue, physical illness and orthopedic injury
had higher concussion symptom scores. However, sex did not
show any significant effects on symptom scores.28 Clinicians
are advised to take all of these factors into account when
evaluating student-athletes.
Majerske et al.29 also examined the role of activity
post injury and its effect on neurocognitive tests. A
cohort design was used to assess the relationship of
symptom status and neurocognitive function after a
concussion. A total of 95 student-athletes were used in
this study.

The ImPACT™ and the Colorado Concussion scale

were used to determine the severity of the concussion,
where the activity intensity scale was used to safely
progress the student into exertional activity.

Results

showed the level of exertion significantly affected symptom
scores and neurocognitive performance.28,29
One of the biggest uncertainties is reliability when
it comes to self-reported symptom tests. It is no secret
that many patients may not be honest when reporting his or

41
her scores. Mailer, McLeod, et al.30 also used a self-report
baseline for a reliability test. The patients used a Graded
Symptom Scale (GSS) which has been modified from the Head
Injury Scale Self Report Concussion Symptoms Scale (HIS).
The subject body of this baseline consisted of 126 middle
school students.

A survey was given to the students; it

consisted of a demographic and life events questionnaire,
along with GSS addressing symptom severity and length.
Scores were added into a Total Symptom Score report and
were found to hold very strong reliability.30 The authors’
results find that healthy youth are reliable with selfreported symptom scales.
It was also found that exertional activity affects a
patient’s postural stability when performing concussion
assessments. Thirty-six college student-athletes were
tested for the effects of fatigue on posture after aerobic
and anaerobic exercises. Postural stability was accessed by
the universal Balance Error Scoring System (BESS) and
scores were compared to a baseline test where no exercise
was performed. Fox, Mihalik, Blackburn, et al.31 revealed
that balance was negatively affected after aerobic and
anaerobic exercise.
The BESS test was specifically examined for
reliability by Brogilio, Zhu, Sopiarz, et al.32 The subjects

42
included 48 volunteers whose mean age was 20 years old (+/2.08). All subjects reported having no prior lower
extremity injury. Participants were given the test a total
of 5 times, each trial was given 50 days apart. Results
found that the BESS held validly and should be considered
being included in most clinicians’ baseline and post injury
concussion testing.

Management of Concussion

Ultimately, management of concussion is what places
pressure on the health care provider. It is imperative that
all health care professionals be proficient in multiple
styles of concussion management. The NATA has set
Educational Competencies which identify the need for
identification and management of concussion. The
competencies that refer to concussion management are not
specific to which management styles should be used.
Noteaert and Guskiewicz15 investigated the current
trends of ATs and their management and assessment of
concussions. They randomly surveyed a total of 2,750 ATs
whom were members of the NATA. Research findings concluded
that the majority of ATs surveyed use hybrid evaluation and

43
management styles; many of these closely resembling the
NATA position statement.
The NATA lays out position statements to help provide
guidelines for all ATs to be consistent with their
decisions, and ultimately make the best decisions for the
patient. The NATA position statement on management of
concussion13 lists multiple grading tools for concussion,
management tools, and return-to-play guidelines. These
guidelines and competencies are helpful when educating ATs,
though there is much gray area in the educational process.
Hunt and Trombley16 investigated via survey the
different management styles of concussion amongst a group
of 120 team physicians. Results found that family practice
physicians evaluated the most concussions per year (30%). A
variety of methods were used during concussion assessment.
Clinical examination and symptom checklists were reported
as the most commonly used methods. Forty-eight percent
reported that the clinical examination is the most
important method when assessing return to play.
One assessment style mentioned by the NATA position
statement is the importance of baseline concussion
testing.13 A survey conducted by Covassin, Elbin, Kontos,
and Stiller-Ostrowski17 investigated the prevalence of
neurocognitive baseline concussion testing in the high

44
school setting. The research concluded there is a high rate
of baseline and post-concussion testing being used by AT’s,
and that symptom scores are weighted heavier than
neurocognitive test scores when returning an athlete to
play.

Athletic Training Education Styles

Education models in Athletic Training Education are
essentially up to the educator. The following section
briefly overviews a few methods used to educate health care
professionals.
The competencies call for the athletic training
education program to identify the signs and symptoms of
head trauma including: loss of consciousness, change in
standardized neurological function, cranial nerve
assessment, and other symptoms that indicate underlying
trauma. It also asks for the curriculum to explain the
importance of monitoring a patient following the head
injury, reviving clearance from a physician to progress the
patient, and to define cerebral concussion33. Though the
NATA identifies these competencies, they do not
specifically designate management or assessment models.

45
This can result to the fact that each protocol can be
altered by the ATs’ medical directors, within the
guidelines of recent literature. However, this can put new
ATs at a disadvantage in their first independent time to
manage concussions.
Covassin, Elbin, and Stiller-Ostrowski34 investigated
the current concussion guidelines and methods being taught
in a classroom, along with tracking the prevalence of the
Vienna guidelines in the educational curriculum. A survey
was sent program directors and ATs which addressed a
variety of questions pertaining to experience and
preference in education style. The majority of results
showed that the NATA position statement was most widely
used in managing concussions along with deciding return to
play protocol. Results found that the Vienna guidelines
were extremely underused. After review of the Vienna
guidelines, 84% of those surveyed stated they would start
teaching the guidelines in their curriculum.
Hankemeier and Van Lunen35 examined the different
experiences and opinions of Athletic Training instructors
when implementing evidence-based practice concepts into
their education program. All clinical instructors
acknowledged the importance of evidence-based practice in
the athletic training profession. Common themes when

46
implementing the practice included: self-discovery,
promoting critical thinking, and sharing information.
Program directors should be implementing evidence-based
practice into the curriculum, along with encouraging
clinical instructors to practice evidence-based
medicine.35,37 A study by Manspeaker and Lunen36 also
identified the need for evidence-based practice in
Commission on Accreditation of Athletic Training Education
(CAATE) programs.

They concluded that educators must

transition towards evidence-based medicine being taught in
athletic training curriculum to provide the most relevant
information to the students.

Measuring Confidence

As in any health care profession, evaluating one’s own
personal abilities and growth is important when trying to
grow as a professional. Confidence is one of the keystones
for having a safe healthcare practice. It is important for

47
healthcare practitioners, to measure confidence when
dealing with certain situations. However, many
practitioners do not realize any deficiencies in their
confidence until they are asked to reflect upon it.
Measuring one’s confidence is descriptive in nature, and
can be difficult to measure. However, self-reflection
through confidence measurements can provide direction for
continuing education, and improving the education
processes.
In fields such as athletic training, physical
therapy, chiropractic, and osteopathy, students are exposed
to real patients in a supervised, clinical situation. These
clinical situations are vital as they introduce the
students into situations they will eventually be placed
into as a healthcare provider, ultimately building
confidence in the individual. Research done by Hecimvich
and Volet19 examined the progress of chiropractic students’
confidence before and after their clinical internships.
Methods of their research included using two large-scale
surveys and randomly interviewing a sub-sample of their
subject base. Tools used to measure confidence included
surveys developed by the authors: the Patient communication
confidence scale, and the clinical skills confidence scale.
Results revealed that before the start of their clinical

48
internships, students had more confidence in patient
communication rather than their clinical skills. After
their clinical internships, both patient communication and
clinical skills increased significantly. The study
highlighted the contributing factors in building
confidence, and found that taking a proactive hand on
approach is the most beneficial.
Other studies investigated different educational
strategies and how it affected the students’ level of
confidence. Chiang, Tan, Chiang, Burge, Griffiths, and
Verbov37 investigated the impact of different educational
methods on confidence levels in dermatology among UK
medical students. Premise for their research being that the
high coincidences of skin conditions make dermatology
education a necessary part of the medical curriculum.
Methods included using survey based research to establish:
educational experience in dermatology, and confidence
levels in the British association of dermatologists core
curriculum learning outcomes, confidence measurements were
rated uses a five point Likert scale. Results found that
students who received education from dermatologists,
dermatology specialized nurses and expert patient, held
higher levels of confidence. Education in clinical settings
and small group settings also revealed the highest levels

49
of confidence.

The authors established that clinical

experiences and small group learning settings are the most
effective in regards to developing confidence.

Summary

The research is very heavy in terms of evaluating,
diagnosing and managing concussions. There are multiple
tools that the ATs are presented with to make the correct
clinical impression in conjunction of giving the best
possible care. Tools range from the newly-developed
computerized neurocognitive assessments to the more
traditional self-symptoms scores. The NATA, along with
other recent literature, outlines these standards both in
competencies for the student and position statements for
the practicing AT. Studies show that educators in athletic
training are able to identify and adapt to their students
learning models. However, there is little literature known
on the relation between concussion management confidence
and its relation to the AT’s continuing education
awareness.

50

51

APPENDIX B
The Problem

52
STATEMENT OF THE PROBLEM

The athletic trainer has to be familiar and current
with the new and established concussion management
guidelines. As the intensity of athletics increases, so
does the potential of concussion, which if not treated
properly, can be life altering. Being familiar with the
current guidelines and putting them to practice in a
confident fashion is also extremely crucial. The most up to
date information is constantly changing. Continuing
education is the tool athletic trainers’ have to keep
current with new practices, the awareness of the athletic
trainer in regards to continuing education may relate to
his/her knowledge of concussion and possibly his/her
confidence in managing concussion.
The purpose of the literature review is to discuss the
continuing education practices of AT’s along with their
concussion management confidence and knowledge. It is
important to examine this relationship because concussion
is a potentially life threatening injury and are very
common in athletics.

It would be beneficial for Athletic

Training Education Programs to evaluate the comfort level
and experience level of new athletic trainers because
alterations in curriculum can be made if research finds

53
that the general subject population feels ill prepared.
Additionally, it would be beneficial for athletic trainers
to know where many of their newly certified peers stand
when dealing with concussions.

54
Definition of Terms
The following definitions of terms will be defined for
this study:
1)

Concussion – A complex neuro-pathophysiological
process affecting the brain, induced by traumatic
biomechanical forces, which include a traumatic
alteration in brain function that is manifested by an
alteration in awareness of consciousness.

2)

Continuing Education - An instructional program that
brings participants up to date in a particular area of
knowledge or skills.

3)

Confidence - Belief in oneself and one's powers or
abilities.

4)

Athletic Training Competencies - A set of required
teaching guidelines an ATEP has to follow.

5)

Baseline Concussion Testing - A pre-season exam used to
assess a patients’ balance, brain function, and any
concussion symptoms.

Basic Assumptions
The following are basic assumptions of this study:
1)

The subjects will be honest when they complete their
demographic sheets.

2)

Subjects will not receive outside help from any other

55
individual or outside source on any question.
3)

The sample is a representation of the population
of athletic trainers.

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

The response rate of the survey could be low due to
busy schedules of the athletic trainers.

2)

As with any anonymous survey, answers might not
be answered honestly by the subjects.

Significance of the Study
Athletic Trainers should possess all the current
knowledge when it comes to concussion. The injury has
proven to be an issue that is frequent in the athletic
training profession. By assessing the athletic training
profession’s current knowledge level, any possible
deficiencies may be detected by this study. If any
deficiencies are identified, it would allow for an
extravagant learning opportunity for both continuing
education practice and athletic training education
curriculums.
Continuing education opportunities can also be
improved depending on the results of this study. Continuing
education awareness for the athletic trainer in regards to

56
concussion management may reveal opportunities to improve
educational programs. The significance of this study aims
to improve the athletic training profession by identifying
the relation between continuing education awareness,
current knowledge and the confidence the athletic trainer
has in regards to concussion management.

57

APPENDIX C
Additional Methods

58

APPENDIX C1
Institutional Review Board –
California University of Pennsylvania

59

60

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Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair
Dear Mr. Christie:
Please consider this email as official notification that
your proposal titled "Continuing Education Participation
Effecting Concussion Management Confidence in Athletic
Trainers” (Proposal #12-037) has been approved by the
California University of Pennsylvania Institutional Review
Board as submitted.
The effective date of the approval is 2-11-2013 and the
expiration date is 2-10-2014. 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 2-10-2014 you must file additional
information to be considered for continuing review. Please
contactinstreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

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APPENDIX C2
Panel of Experts Letter

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Hello,
My name is Zak Christie, I am a graduate Athletic Trainer
at California University of Pennsylvania. I am conducting
research with Dr. Linda Meyer and am using a survey. You
were highly recommended as an expert in the field of
concussion. I am asking for you to sit on my panel of
experts for this survey.
Please let me know if you are NOT able to assist me with
this survey. If you are able to assist, I kindly ask if
you would please reply no later than Monday, November 23,
2012.
Either way, thank you for your time; I greatly appreciate
it. Thank you for your time and consideration.
Very Respectfully,
Zak Christie

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APPENDIX C3
Concussion Knowledge and Confidence Survey

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APPENDIX C4
Cover Letter

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3/18/2013
Dear Fellow Certified Athletic Trainer:
My name is Zachary Christie 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 complete a research thesis
through conducting research. I am conducting survey
research to determine the current knowledge level of
concussion and the educational factors effecting confidence
in certified athletic trainers. This Data will allow the
Athletic Training profession to further our own knowledge
in regards to concussion management.
Certified athletic trainers whom are members of the
National Athletic Training Association are being asked to
participate in this research; 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 without
penalty; however your data will be discarded. The
California University of Pennsylvania Institutional Review
Board has reviewed and approved this project. The approval
is effective (2/11/2013 and expires 2/10/2014).
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 as
it will take approximately 10 minutes to complete. If you
have any questions regarding this project, please feel free
to contact the primary researcher, Zak Christie at
CHR8755@CalU.edu. You can also contact the faculty advisor
for this research, Linda Platt Meyer, EdD, LAT, ATC at
Meyer@calu.edu. Thanks in advance for your participation.
Please click the following link to access the survey
(www.surveymonkey.com/s/RXRJMYZ).
Thank you for taking the time to take part in my thesis
research. I greatly appreciate your time and effort put
into this task.

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This student survey is not approved or endorsed by NATA. It
is being sent to you because of NATA’s commitment to
athletic training education and research.
Sincerely,
Zachary Christie LAT, ATC
California University of Pennsylvania
250 University Ave
California, PA 15419
CHR8755@CalU.edu

88

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ABSTRACT

TITLE: CONTINUING EDUCATION AWARNESS EFFECTING CONCUSSION
MANAGEMENT CONFIDENCE IN ATHLETIC TRAINERS
RESEARCHER: Zak M Christie, LAT, ATC
ADVISOR: Dr. Linda Platt Meyer
PURPOSE: To discuss the continuing education practices of
AT’s along with their concussion management confidence and
knowledge.
DATE: May, 2013
Design: Descriptive Survey
Settings: Population-Based Survey
Participants: One-thousand ATs were asked to volunteer.
Subjects were randomly selected from the ten districts
through the NATA database. The final response rate was 169.
INTERVENTIONS: The dependent variable is the confidence of
ATs in regards to concussion management. The independent
variable is continued education awareness that ATs have
with regards to concussion.
RESULTS: There was no significance found in the hypothesis.
However there were additional findings which could lead to
further research in concussion knowledge throughout
Athletic Trainers.
CONCLUSIONS: Based on the results of this study, we can
conclude that continuing education awareness does not
relate to concussion management knowledge and confidence.