Jan 29, 2015
From Hands to Head

With new research and guidelines out on how to assess concussions, now is the time to update your protocols.

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning.

Three years ago, Dale Mildenberger, MS, ATC, Associate Athletic Director and Head Athletic Trainer at Utah State University, decided that he did not feel comfortable with how his athletic department assessed concussions. The protocols did not provide adequate direction, were not based on objective measures, and were not in line with the latest research, he says. So with the school’s team physician by his side, Mildenberger began looking for something better.

He knew he wanted to incorporate some baseline testing, and he wanted to measure his athletes’ cognitive recovery as well as their physical balance. After doing extensive research, Mildenberger instituted a concussion protocol that has made his decisions easier and his athletes safer. He fine-tunes his protocol annually and after reviewing it this year, found that it falls in line with the NATA Guidelines on sport-related concussion issued last fall.

Starting his concussion review process three years ago, Mildenberger was ahead of the curve. Today, however, as parents and the mainstream media pay more attention to the risks associated with concussions, every athletic trainer clearly needs a return-to-play protocol that takes into account the latest research and advice on concussions.


The first step in updating concussion assessment procedures is to make sure your institution’s overall policy on return-to-play decisions is appropriate. There should be a medical chain of command, whereby an injured student-athlete can only return to play when authorized by designated personnel. And this policy should be in writing, cleared by those in charge of student-athlete health and safety.

Although this policy should cover more than concussions, it is especially helpful when dealing with something as controversial as head injuries. “The whole purpose of having policy-backed procedures in place is to have some predictability in what you’re going to do in difficult circumstances,” says Richard Ray, EdD, ATC, Athletic Trainer and Program Director for the Athletic Training Education Program at Hope College.

“The policy needs to state that the person who has the final authority over participation when it comes to medical issues is the designated team physician or the highest ranking medical authority employed by the school—the athletic trainer,” says Ray, who is the author of Management Strategies in Athletic Training, Counseling in Sports Medicine, and Case Studies in Athletic Training Administration. “He or she should be empowered by the school board or by the board of trustees at the institution to make medical decisions regarding fitness for participation.”

In other words, if an athlete’s personal physician clears him or her to play, but the athletic trainer or team physician does not feel the concussion has healed, the athlete will be kept on the sidelines. If the athlete or parents complain, the athletic trainer can direct them to the institutional policy.

If the policy states, as Ray suggests, that the team physician is at the top of the chain, it’s also important that your athletic department retain a team physician you can work with on building a concussion protocol. “The most important thing is to have a dedicated, knowledgeable, committed physician who is willing to serve as the medical director for your program,” says Ray. “That person should be willing to make judgements to withhold participation in the face of highly motivated athletes, parents, and sometimes coaches who don’t completely understand the risks of allowing a kid to return to participation.”

The team physician and athletic trainer should work on the specific concussion guidelines as a team. Along with looking at the latest research and advice, they can receive guidance from the NATA’s position statement on handling concussions released last fall. Most important, they should agree on a philosophy and a consistent approach, regardless of the athlete, sport, or circumstances surrounding the injury.


One of the key decisions the athletic trainer and physician will need to make is whether to use baseline testing when assessing concussions. Such testing measures healthy athletes’ neurological functions, which establishes a “normal” baseline—a score that is revisited following a suspected concussion. Athletes should not return to play until their scores on the test return to their own baseline.

Most agree that baseline testing is the most accurate way to determine if an athlete is ready to return to play. But it does take some up front work.

The most sophisticated and time-efficient method of baseline testing involves computer-based neuropsychological exams. “We baseline all of the incoming freshmen and players new to the school,” says Detroit Country Day School Athletic Trainer Cheryl Williams, ATC. “The test is good for two years. Then we re-baseline them before their third year so we have an updated version in the system.”

The test takes 25-30 minutes per student, and is administered in the school’s computer lab, where 10 people can be tested at one time. Computer-based tests measure aspects of brain function that are most vulnerable to the injury such as memory, attention, concentration, reaction time, problem solving, mental speed, and processing speed.

“It’s made my life 100 percent easier, because before, the role of the athletic trainer was just to keep concussed athletes out,” says Williams. “Now, we have more data to back us up in holding them out and managing their injuries. I feel like my athletes are safer because of it.”

Utah State decided it did not want to use computer-based testing, but still wanted to baseline its athletes’ cognitive levels and balance. Mildenberger thus chose two tests to use: The Standard Assessment of Concussion (SAC) and the Balance Error Scoring System (BESS). “We chose those tests because they were fairly inexpensive, well-respected, and the most widely used in terms of measuring cognitive values and balance,” says Mildenberger.

The SAC is a mental-status exam that tests orientation, immediate and delayed memory, and concentration, while allowing for neurologic examination and clinical evaluation of exertion, coordination, strength, and sensation. The BESS is a clinical test battery that uses modified stances on different surfaces to assess postural stability.

Establishing baseline scores for both tests takes about 20 minutes per athlete, says Mildenberger, and is part of each incoming athlete’s pre-participation physical. The scores are put into each athlete’s medical file and are kept on hand in their team’s travel kits. Scores are used for the duration of the athlete’s career.

Because of the time requirement of the testing, Mildenberger says the key is to train other staff members to help conduct the exams. “Part of our protocol is the annual training of our staff to administer the tests so that we have consistency,” he says. “By doing this, we’re not dependent on having the same person available to do baseline testing and follow-up exams.” Mildenberger has also developed a videotape of the procedure, which each athletic trainer views and is tested on.

Currently, Mildenberger is testing whether coaches can administer the baseline testing at three nearby high schools, which are in the process of installing the protocol used by Utah State. “It has taken an effort on our part to train people in the proper administration of those tests, but it is not extensive,” says Mildenberger. “Coaches and athletic trainers meet with us for three hours. We also do individual training with those people collecting the baseline data.”

Because of the developmental changes that an adolescent goes through during the high school years, Mildenberger is also investigating the need to re-baseline high school athletes, as Williams does. “This year we will begin testing to see if a follow-up exam between the sophomore and junior years reveals any significant difference in balance or intellectual ability,” he says.

For those time-crunched athletic trainers with concerns about being able to schedule baseline exams for all their athletes, John Reynolds, MS, ATC, Athletic Trainer at George C. Marshall High School in Falls Church, Va., recommends prioritizing teams that are at greater risk of having athletes sustain concussions. Then, when putting together a baseline testing schedule, make sure those higher-risk athletes are the first to be screened. After all, the odds of golfers getting a concussion aren’t nearly as high as those of football or soccer players.


Whether or not you choose to use baseline testing, developing return-to-play protocols is a critical step. Most experts agree that the protocols need to include a combination of screening tools appropriate for sideline use that test cognition as well as postural stability. Sideline evaluations should also include a symptom checklist that can be filled out immediately following a head injury.

The NATA mentions three approaches in its position statement on Management of Sport-Related Concussion:

  • Grading the concussion at the time of the injury.
  • Deferring final grading until all symptoms have been resolved.
  • Rather than using a grading scale, focusing attention on the athlete’s symptoms, neurocognitive testing, and postural-stability testing.

Mildenberger’s return-to-play criteria follows the NATA’s third suggestion. And it is the same process whether he’s evaluating an athlete 15 minutes after the initial injury or seven days later. When an athlete is suspected to have sustained a concussion, an athletic trainer administers the SAC and the BESS on the sideline or in the locker room, and compares the athlete’s scores against his or her baseline numbers. A post-injury portion of the SAC also requires evaluating symptoms with regards to exertion, coordination, strength, and sensation. Before allowing an athlete to return to play, Mildenberger also initiates an exertional maneuvers test, in which the SAC and the BESS test are re-administered after the athlete has been put through a series of physically demanding exercises.

Reynolds, who utilizes baseline screening whenever possible, has established a return-to-play protocol that hinges on athletes being symptom-free after strenuous exercise. “Once they can pass exertion tests that include push-ups, sit-ups, and some running without becoming symptomatic—headache, dizziness, anything unusual—then you can begin to reevaluate their status as far as practice goes,” says Reynolds. “That can be a fairly lengthy process, and the students, coaches, and parents need to understand that there’s a real need to reintroduce the individual gradually to increasing demands of activity.”

At Detroit Country Day, students with head injuries are given a sideline evaluation and subsequent neuropsychological test. If a student is found to have a concussion, he or she is restricted from competition and Williams is responsible for contacting Kenneth Podell, PhD, co-founder and Director of the Sports Concussion Safety Program at Henry Ford Hospital in Detroit. Podell, who initiated the program at Detroit Country Day, re-tests the athlete 48 hours later during an examination at his office. If the athlete’s follow-up score matches his or her baseline number, the athlete goes through exertional training and takes a symptom test to see if any symptoms recur. Then, based on whether or not symptoms exist, and the athlete’s concussion history, Williams and Podell determine if that athlete should be allowed to return to play.

Even though baseline testing is highly recommended by authorities such as the NATA, it is important to note that even without having baseline scores to use as comparisons, the SAC and BESS tests have both been proven to be effective sideline assessment measures. When baseline scores are not available, it is important to conduct an evaluation immediately following the injury. Then, while closely monitoring any symptoms and behavior, re-testing should take place 15 to 20 minutes following the injury, when the athletic trainer can compare the scores to determine whether or not the athlete’s cognitive ability and postural stability have improved. If the athlete is symptom-free, the athletic trainer may allow that athlete to return to competition. However, if symptoms remain, or if their SAC or BESS scores have not improved, the athlete should be pulled from competition and remain under the careful observation of the athletic trainer until further testing can be completed.

“It’s not quite as good as having a baseline number to compare it to, but it does allow us to say, ‘You scored this a half an hour ago, and now you scored this,'” says Reynolds. “Based on the scores, the athlete is either staying the same, improving, or not improving. That helps you make your immediate decision: Are they going home with mom and dad to be observed? Or are they being rushed to the hospital in an ambulance?”


An important component of any concussion management protocol is education. By sharing what they know about the latest in concussion research with coaches, student-athletes, and parents, athletic trainers can back their treatment with science and expert opinion.

One convenient way to educate student-athletes and parents is to share your athletic department’s concussion protocol on your school’s Web site. You can also add links to the latest concussion research as well as e-mail addresses for the sports medicine staff.

Another method is to present a five-minute speech at teams’ preseason parents meetings, especially in sports with a higher incidence of concussion. Reynolds does this as well as providing handouts that include the school’s injury assessment and management guidelines. He says that this approach has been very effective at his school for fostering awareness about the symptoms of the injury and the dangers of returning before being fully healed.

In fact, it helped lead one athlete to spot a concussion in a teammate. “One of our student-athletes came to us during a football practice and said his teammate was laughing and being very silly in the huddle—which was very atypical for that athlete—and that he thought something was wrong,” says Reynolds. “So I pulled that kid to the side and started talking to him and it was very clear that something was not right. I continued the evaluation process, and sure enough, he had sustained a fairly significant concussion and the only symptom that was initially recognizable was a change in personality.”

If an athlete does experience a concussion, Ray suggests seizing that time to intensify the educational message program-wide. “When we have an athlete with a concussion, not only do we educate the athlete about the procedure and what needs to happen before he or she can play again, we talk to the coach in the very same terms, so the coach feels like a partner in the process,” says Ray. “That way, a coach feels fully informed, and a fully informed coach is more likely to be on board with the program. I think it’s counterproductive to say to a coach, ‘We’ll just let you know when a kid is ready to go back.'”

At the high school level, it may also be important to educate other health care professionals in the community about your updated concussion procedures. “Especially with smaller schools,” says Jon Almquist, ATC, Athletic Training Program Specialist at Fairfax County (Va.) Schools, “you want to get the physicians in the community on board with your ideas. Because a lot of times, the typical pediatrician has very little understanding of what the new research is in concussions.”


Despite all of the research and subsequent guidelines that have accompanied heightened concussion attention, one message remains consistent: No athlete should return to play unless he or she is 100-percent healed and completely symptom-free. So whatever course is taken, athletic trainers needs to develop policy-backed protocol that is focused on the student-athlete’s safety and long-term health.

A comprehensive policy gives athletic trainers confidence, and allows them to tune out all peripheral distractions when making a decision. And by building that policy around objective assessment tools or even computer-based neuropsychological tests, athletic trainers are able to put themselves in the best possible position to make decisions that are in the best interests of their student-athletes.

A version of this article is also appearing in T&C’s sister magazine, Athletic Management.

Sidebar: Message to Coaches

To help high school coaches get on board with new concussion guidelines, the state high school athletic association in Texas has begun to provide coaches with a pocket-sized concussion-grading card. The card contains instructions on how to recognize symptoms of concussions and provides treatment recommendations.

“For athletic trainers, it’s not new information, but for those people who don’t deal with injuries on a daily basis, it makes a big difference,” says William “Hondo” Schneider, MS, ATC, Head Athletic Trainer at Midland Lee High School in Texas. “It’s not a perfect instrument, but it gives people on the sidelines a better idea of what to do. It’s a start in the right direction.”

Kenneth Podell, PhD, co-founder and Director of the Sports Concussion Safety Program at Henry Ford Hospital in Detroit says the card serves a couple of purposes. “Number one, it increases awareness, and number two, it creates a level of accountability,” he says. “The card sends a message to coaches saying, ‘Things are changing and you guys need to change too.'”

The card lists the symptoms of three grades of concussion and explains what a coach’s course of action should be for each grade. Schneider says that at his school, coaches are required to call the athletic trainers if they suspect a concussion of Grade 2 or higher. There are also recovery guidelines that suggest when an athlete can return to play.

“The card explains to coaches what the new standard of care for a concussion is,” says Podell. “It explains how a concussion should be treated, and that if one of their players has a concussion that player had better be evaluated. It’s now holding the coaches responsible.”

For more information about the Management of Concussion in Sports card, call the Brain Injury Association of America’s bookstore at (800) 565-0668.

Sidebar: Does Soccer Need Headgear?

When the Santa Clara University women’s soccer team played its way into the NCAA Division I semifinals last December, they got recognition not just for their on-the-field moves, but also for the funky headgear they were wearing. To help prevent concussions, the majority of team members competed last season with protective equipment that looks like an enlarged headband and provides padded coverage to the forehead, temples, and occipital bone in the back of the head.

A handful of soccer players, from youth leagues to the 2004 Olympics, have also donned the headgear, but the jury is still very much out on whether they are needed or effective. In a study conducted at Washington University in St. Louis, researchers tested four models of headgear for their effectiveness in decreasing impact forces during heading of the ball. Researchers exposed the headgear to soccer balls at various inflation levels, propelled at speeds of 20, 26, and 34 miles per hour.

“In terms of heading the soccer ball, we found that really only at the highest speed did it make a difference, and it was a very small difference,” says Rosanne Naunheim, the study’s lead author and an Assistant Professor of Emergency Medicine at Washington. Because a soccer ball and the headgear are about equal in terms of softness, there’s not much change in the soccer ball force and acceleration when the ball hits the headgear, she explains.

But what about concussions caused by collisions? The University of North Carolina’s women’s soccer team is sponsored by one of the headgear companies, Full90, and Head Coach Anson Dorrance feels anything that can reduce peak impact forces during a collision is well worth it. “I’d challenge any of these doctors who feel this has no value to run into the goal post without a Full90 and with it, then tell me, if they were forced to do it a third time, whether or not they would wear it,” Dorrance told The New York Times.

But Kevin Guskiewicz, who studies concussions as a Professor and Director of the Sports Medicine Research Laboratory at the University of North Carolina, is not smitten with the idea. Guskiewicz says that by wearing headgear, players could gain a false sense of invulnerability, thereby making them more aggressive. He also says adding extra weight to the heads of young players may be detrimental.

“Quite frankly, headgear has not been studied well enough and it is entirely too early in the game to mandate headgear for soccer players at any level of play,” says Guskiewicz.

Brian Goodstein, Athletic Trainer for Major League Soccer’s DC United, says that most of the head injuries he sees in soccer are more a result of a jarring of the brain than a direct blow to the head. “With that in mind, I feel that wearing the headgear can’t hurt,” says Goodstein. “But how much does it help? That’s something I don’t know.”

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