Concussion Management Protocols In The Military And The Role Of The Athletic Trainer: A Systematic Review

Journal of Athletic Training. -


Bergens, B. L.-F., T. M. Kasamatsu and M. A. Cleary.



Context: Athletic trainers are on the forefront of managing mild traumatic brain injury or concussions in the physically active population. However, in the various military settings, other health care professionals tend to fill the role of concussion management. Incidence rates are increasing in theaters (combat) such as Operation Iraqi Freedom and Operation Enduring Freedom largely due to increased symptom awareness and increased use of improvised explosive devices. Many of the concussion management protocols in the military have been developed from sport-related concussion research, with one difference being the small number of athletic trainers working with soldiers in garrison (domestic base). Objective: To critically analyze the concussion management protocols of the military and determine the potential role athletic trainers could fulfill while working in this emerging practice setting. Data Sources: A computerized search for relevant articles was performed using the databases PubMed, Military and Government Collection, SPORT Discus, and Health Source: Nursing/ Academic edition from 2000-2012. The search was conducted using the keywords: concussion management and military, sport concussion epidemiology, sport-related concussion, and WARCAT. Limits were: published in peer reviewed journals, full text available, English, and humans. Study Selection: Articles were selected by reading the abstract, scanning headings and titles for relevance to concussion injuries in the military, sport-related concussion, management protocols, duties of healthcare professionals and athletic trainers. Data Extraction: Full-text of 22 articles was reviewed, we summarized major findings in a spreadsheet and scored each article on the Strength of Recommendation Taxonomy (SORT) or if the article contained human subjects we scored it using the Physiotherapy Evidence Database (PEDro) scale. Data Synthesis: Data were synthesized by categorizing the SORT levels of evidence and summing the frequency of each level of evidence (1 through 3). We found that 86.4% (19/22) of the articles were not human subjects and were scored as SORT Levels of Evidence 3 and 13.6% (3/22) were scored 2. For the 22.7% (5/22) of articles that included human subjects, the PEDro score was 5±0 points. Conclusions: The military recognizes the importance of concussion management and implements current research into their management protocols. The Military Acute Concussion Evaluation was adapted from the Standardized Assessment of Concussions and is used to diagnose and help guide a safe return to duty. Neuropsychological batteries such as ImPACT have been validated and implemented in garrison and in theater. As opposed to in garrison, concussion management in theater is complicated by access to medical resources, remote locations, and duration of missions. Athletic trainers’ understanding of concussion management and coordination with military personnel may positively impact the soldier’s standard of care upon return from theater. Concussion management in garrison needs continued investigation and development which may be where athletic trainers can make the greatest contribution.

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