More Than a Bump: Supporting ATs in the Fight Against Concussions and the Role of Critical Management

In sports, where milliseconds decide success or failure, athlete safety is crucial. As an experienced athletic trainer, I've seen how concussions extend beyond minor bumps. We no longer just tell athletes to "shake it off." Concussion care is complex, needing an evidence-based, interdisciplinary approach. Improper management can cause prolonged symptoms, cognitive issues, mental health problems, and rare disastrous outcomes. The NATA's revised "Bridge Statement: Management of Sport-Related Concussion" marks a major update, integrating the latest research to improve concussion management. It consolidates ten years of findings into new guidelines for education, return-to-play, and more. This document equips sports medicine professionals to better protect athletes and promote their long-term health, urging a proactive, athlete-centered approach.

The 2024 NATA Bridge Statement: Empowering Athletic Trainers and Sports Medicine Professionals

The 2024 NATA Bridge Statement links the 2014 position with current concussion evidence, guiding athletic trainers (ATs) and sports medicine professionals with scientific research. It updates best practices, emphasizes biopsychosocial factors, and underscores the ATs' crucial role in athlete health. The publication details over 25 updated or new rules and recommendations on:  

The 2024 Bridge Statement notes ATs working with administrators to inform stakeholders on concussion management. Administrators must ensure that medical practitioners are qualified and authorized. ATs should apply culturally sensitive methods, considering sociocultural factors influencing concussion perceptions and care. 

• Evaluation: Significant changes have occurred in SRC assessment over the past decade. The Bridge Statement highlights advances in assessment tools, their timely use, and challenges from injury variability and symptom non-specificity. The clinical assessment, including cervical spine and neurological exams, remains the gold standard, with visual-vestibular function gaining importance. The declaration calls for mental health screenings to improve care and outcomes.  
• Prognostic Factors: ATs and healthcare personnel should consider moderating factors affecting concussion recovery, including symptom load, prompt care-seeking, visual-vestibular impairments, and socioeconomic determinants. Understanding these helps tailor management approaches.  
• Mental Health Considerations: This section outlines strategies for identifying and referring secondary school and college athletes with psychological issues. Screening for mental health disorders should be part of preparticipation evaluations. Health professionals should adopt a biopsychosocial approach, including patient-reported outcomes.  
• Returning to Academics: Beyond athletic exclusions, concussion care requires athletes to avoid activities that risk further brain damage. ATs should know the levels of academic support and collaborate to develop personalized plans for student-athletes' academic return. An interdisciplinary school-based team should also be formed to support this process. 

The Bridge Statement highlights that early, controlled aerobic exercise—starting 1 to 2 days after injury—is safe and beneficial. It advocates for targeted active rehab within concussion protocols under a clinician's guidance. The statement emphasizes collaboration among ATs, healthcare professionals, and administrators to improve concussion prevention and management. It notes cognitive testing limits during acute injury and stresses understanding academic support and personalized care planning.

The Importance of Awareness and Education  

Concussion awareness relies on education. ATs, athletes, coaches, parents, and administrators need thorough knowledge of prevention, recognition, and management. All must understand signs, symptoms, harm processes, and potential implications of poor management. ATs play a key role in educating stakeholders, including proper terminology like "concussion" or "mild traumatic brain injury," rather than informal terms like "ding."² Education should clarify gear limitations and identify licensed medical experts, such as sports trainers and physicians, who hold authority in concussion decisions.¹ 

Sideline Assessments and Reliable Tools 

Prompt sideline evaluations are crucial for identifying athletes who may have sustained a concussion. An exhaustive, evidence-based assessment is crucial for precise diagnosis and to establish suitable management options. These evaluations cannot depend exclusively on any singular metric but must integrate a holistic therapeutic perspective.^3-4 Here are the many pieces of the concussion puzzle. 

• Clinical Assessment: The clinical exam is essential for sideline evaluation, including neurological, neuropsychological, motor, balance, and visual-vestibular assessments, as visual-vestibular function is crucial in concussion. The Bridge Statement stresses the need for thorough cervical spine checks to rule out other injuries that could mimic or worsen concussion symptoms.³ 
• Symptom Evaluation - A Principal Indicator: The study published in JAMA Network5 highlights the importance of symptom reporting for concussion identification, with a rise in symptom scores being a key indicator. ATs should diligently record athletes' subjective experiences and observe deviations from baseline. The Harmon study showed that a 2-point increase in scores had an 86% sensitivity and 80% specificity for diagnosis. Despite challenges in relying on symptoms, ATs should consider cultural sensitivity and truthful communication and ensure that the athlete can accurately convey their symptoms.  
• The Standardized Assessment of Concussion (SAC) - Utility and Limitations: The SAC's diagnostic value in concussion assessment has declined. The Harmon study showed its cognitive components had limited sensitivity, with nearly half of concussed athletes scoring at or above baseline. The study found that orientation and concentration offer little diagnostic value. Clinicians should understand these limits and interpret scores cautiously. Notably, drops in SAC scores, particularly in memory, can offer more insight.⁵ 
• Visual-Vestibular Function: ATs should regard visual-vestibular function as a critical component in concussion evaluations, employing instruments such as eye tracking and gaze stability assessments.¹  
• Using A Multimodal Approach: It is essential to recognize that no singular test or assessment should determine the diagnosis.⁵ ATs should employ a multimodal approach, integrating information from the clinical evaluation.  
  
  • The Clinical Exam 
  • Symptom documentation  
  • Objective assessments of cognitive and sensorimotor functions, with meticulous attention to their limitations.  
  • Visual Indicators and Vestibular-Ocular Elements.  
• The Significance of Normative and Baseline Data: In interpreting results, ATs should consider population-based normative data and, ideally, the individual's baseline scores. Comparing to baseline offers a more personalized approach, but they must also recognize that normative values can vary by age, sex, and other factors variables.⁶  
• The biopsychosocial approach enhances concussion management by considering the physical, cultural, social, and psychological factors that influence patient care.1 Cultural sensitivity and culturally safe care must be integrated throughout the concussion care continuum, impacting all aspects from education to assessment and recovery. 

Return-to-Play Protocols 

Of paramount importance is a systematic and prudent return-to-play (RTP) program to avert additional injuries and safeguard the athlete's long-term well-being. The protocol must be tailored and directed by symptoms, with each phase necessitating a minimum duration of 24 hours.⁷ This process should include:⁷  

• Symptom-Limited Activity: Daily tasks that do not aggravate symptoms. 
• Aerobic Exercise: Commence with light intensity, progressing to moderate intensity, contingent upon the absence of symptom exacerbation.  
• Sport-Specific Exercise: Personalized training tailored to the individual sport, conducted outside the team setting. 
• Non-Contact Training Drills: Elevated intensity exercises conducted inside a team environment without physical contact. 
• Full-Contact Practice: Standard training exercises aimed at rebuilding confidence and evaluating functioning abilities.  
• Resumption of Sport: Standard gameplay.  

Clinically supervised physical activity, including prescribed aerobic exercise, is now regarded as a treatment or "medicine" for concussion when applied correctly, highlighting that athletes may commence a gradual return to activity following a brief rest period of 24-48 hours, provided symptoms remain stable and exertion does not exacerbate them.^1-3 

Conclusion

Concussion treatment will remain vital in sports medicine. The 2024 NATA Bridge Statement offers a framework for ATs and healthcare professionals focused on athlete welfare. Adopting these updates allows us to move beyond outdated methods and provide personalized, evidence-based care. It is crucial to move beyond viewing concussions as minor and recognize their complexity.  

We must promote comprehensive education, use advanced assessment tools, and follow detailed return-to-play protocols. Adopting the biopsychosocial model highlights the link between physical, psychological, and social factors in recovery. Let's commit to the NATA Bridge Statement and work together to protect athletes from the short- and long-term effects of concussion, ensuring they return not only physically healed but also psychologically ready to perform at their best. The future of athlete safety depends on it. 

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References

1. National Athletic Trainers' Association (NATA). (2024). Bridge Statement: Management of Sport-Related Concussion. Journal of Athletic Training, 59(3), 225 – 242. 
2. Broglio, S. P., Cantu, R. C., Gioia, G. A., Guskiewicz, K. M., & et al. (2014). National Athletic Trainers' Association position statement: management of sport concussion. Journal of Athletic Training, 49(2), 245-265. 
3. Leddy, J. J., Haider, M. N., Ellis, M. J., Willer, B. S., & et al. (2021). Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial. The Lancet Child & Adolescent Health, 5(11), 792-799. 
4. McCrea, M. (2001). Standardized mental status assessment of sports concussion. Clinical Journal of Sport Medicine, 11(3), 176-181.  
5. Harmon, K.G., Whelan, B.M., Aukerman, D.F. et al. Diagnosis of Sports-Related Concussion Using Symptom Report or Standardized Assessment. JAMA Network Open . 2024;7(6):e2416223. 
6. Schmidt, JD, Register-Mihalik, JK, Mihalik, JP, Kerr, ZY, Guskiewicz, KM. Identifying impairments after concussion: normative data versus individualized baselines. Med Sci Sports Exerc. 2012;44(9):1621-1628. 
7. Patricios, J. S., Schneider, K. J., Dvorak, J., Ahmed, O. H., & et al. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport—Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695-711. 

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