National Athletic Trainers’ Association updates clinical recommendations

By Sarah Brown. This article was initially published in the 4/11/24 edition of our Concussion Update newsletter; please consider subscribing.

In late March, the National Athletic Trainers’ Association released its updated recommendations for the management of sport-related concussions – a document that hadn’t been updated in over a decade. Published in the Journal for Athletic Training, their ‘Bridge Statement’ provides more than 25 novel or altered recommendations to reflect current scientific findings regarding best practices for concussion management. The authors, Broglio et al., assert the ongoing importance of this work, “Despite substantial advances in the science, sport-related concussion (SRC) continues to be a serious concern at all levels of sport.” The updated recommendations span topics from guidance about driving to mental health assessments. In an interview for Medical Express, lead author Dr. Broglio explained that the updated recommendations incorporate information from the most recent international Consensus Statement on Concussion in Sport, published in 2023.  

The new recommendations employ a biopsychosocial model – where biological, psychological, and social factors are central to concussion recovery. On the biological front, Broglio et al. added the need to test patients’ visual-vestibular systems within concussion assessments, as well as examine the cervical spine for issues. As the utility of baseline testing has been called into question, the authors downgraded this form of testing from a ‘mandatory’ part of the concussion assessment process to only circumstantial use. Additionally, in lieu of the guidance to postpone physical exertion until the patient receives a routine clinical examination, the team asserts that “controlled, subsymptom threshold aerobic exercise training can begin as soon as 1-2 days after injury, provided resting symptoms are stable [(not getting worse)] and not severe.” Broglio et al. reference the potential for early aerobic exercise to improve outcomes and recovery. See the report for specific guidance on the nature of the progression of physical exertion. Lastly, during the acute stage of recovery (24-48 hours post-injury), the team altered the instructions from avoiding any activities that exacerbate symptoms to only avoiding those that exacerbate symptoms ‘more than mildly.’ 

On the psychological front, the new recommendations include a mental health screening for mood, psychiatric distress, anxiety, and depression. In addition to post-concussion mental health assessments, the new guidance asserts that a mental health assessment should be ‘a standard aspect of the preparticipation examination.’ Broglio et al. assert that all athletic trainers should know that prior concussion history is associated with higher rates of psychological difficulties. Additionally, those with preexisting mental health conditions or a family history of psychiatric or mood disorders appear to be associated with prolonged concussion recoveries. After the mental health assessment, the guidance recommends that athletic trainers refer patients to mental health specialists as appropriate. 

In the social domain, the guidance now incorporates a list of ‘risk factors for delayed or difficult recovery’ that align with the latest literature. These factors include delayed access to care and care-seeking; continued participation after injury; symptoms, such as greater severity and visual-vestibular deficits; sleep issues; repetition of concussions; age, with adolescence being the largest risk factor; comorbidities, such as depression, migraine, and other mental health disorders; high-risk sports; and social determinants of health, such as health care access and insurance. Broglio et al. call for an interdisciplinary school-based concussion management team to help the student transition back to academics after 24-48 hours of cognitive rest. The statement emphasizes the importance of a gradual, stepwise strategy for the return-to-learn process, which may include an array of academic supports.