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mcguine@ortho.wisc.edu
The Availability of Athletic Trainers in Secondary Schools:
Implications for the Recognition and Management of Sport
Related Concussions
Tim McGuine PhD, ATC
(mcguine@ortho.wisc.edu)
mcguine@ortho.wisc.edu
Disclosures
Current COI
Neither I, nor any family member(s), have any relevant financial relationships to
be discussed, directly or indirectly, referred to or illustrated within the
presentation.
Funding
Advisory Affiliations
mcguine@ortho.wisc.edu
Prevalence of SRCs in
Wisconsin High Schools
0%
5%
10%
15%
20%
25%
30%
9 10 11 12
Boys Soccer Girls Soccer Football
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Prevalence of SRCs in
Wisconsin High Schools
13.0%
17.6% 18.6%
0.9%
2.7% 1.9%
0%
5%
10%
15%
20%
Boys Soccer Girls Soccer Football
1 SRC
2+ SRC
BACKGROUND
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1) Historical evidence that a substantial number of
SRCs may go unreported.
2) Athlete’s recovering from SRCs may be allowed to
return to sports prematurely without proper
medical supervision
3) No large-scale studies in Wisconsin on the
incidence, impact and management practices for
SRCs in high school athletes.
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1) Determine the level of AT employment
in WI high schools
2) Secure research funds
3) Collect SRC incidence and
management information in WI schools
with different levels of AT availability
A Multi-Step Process
FIRST STEPS
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1) 2015 - Research grant
“Utilization of athletic trainers in high school settings.”
2) Survey School AD’s and ATs who may work in high schools
settings
a) Employer (if not the school district)
b) Contract
c) Coverage details
The First Step
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Wisconsin AT Availability
1) > 95% had access to an AT
2) Availability and services performed
varied considerably
3) School enrollment was not correlated
with AT availability
4) Compare SES and AT availability
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Journal of Athletic Training 2018;53(11):000–000 doi: 10.4085/1062-6050-440-17© by the National Athletic Trainers’ Association, Inc www.natajournals.org
School and Community Socioeconomic
Status and Access to Athletic Trainer
Services in Wisconsin Secondary Schools
Eric Post, PhD*; Andrew P. Winterstein, PhD, ATC*; Scott J.
Hetzel, MS†; Blaire Lutes, BS‡; Timothy A. McGuine, PhD,
ATC‡
Results
SES correlated with AT access!
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The Next Step…..
(NATA-REF) 15OUT003
The Impact of Athletic Trainers on the Incidence and
Management of Concussions in High School Athletes
RESEARCH PLAN
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Plan: Assign schools to 1 of 3 groups based on their AT access
1) High-level of AT availability (HiAT)
2) Mid-level availability (MidAT)
3) Low-level AT availability (LoAT)
Specific Aim 1: To compare the incidence of SRCs
Specific Aim 2: To compare SRC management practices
Specific Aim 3: To determine the health outcomes (symptoms,depression and HRQoL) in subjects with SRCs
Study Aims
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Research Overview
Design: Prospective cohort study.
Participants: 2200+ athletes from 30 high
schools
Interventions: Self-report measures of: 1) quality
of life, 2) depression and 3) SRC symptoms
ATs record all SRC injuries that occur during the
sport seasons.
SRC’s complete baseline measures at various
time points up to one year post injury.
Analyses: logistic regression model followed by a
multivariate Cox-PH model.
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AT / School Scenarios
#1 Enrollment: 240, Fall participants: 70
AT: 0.5 - 1.0 hrs. / week
#2 Enrollment: 620, Fall participants: 130
AT: 25 - 35 hrs. / week
#3 Enrollment: 1560, Fall participants: 582
AT: 30 - 35 hrs. / week
#4 Enrollment: 1210, Fall participants: 380
AT: 75 - 90 hrs. / week
AT availability = number of athletes the AT was
expected to serve per hour (athletes/AT hour).
HiATC (= < 20.0 athletes/AT hour)
MidATC (20.0 – 40.0 athletes/AT hour)
LoATC (= > 40.0 athletes/AT hour)
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Analyses For
1) SRC Incidence
2) Time until examined by AT
3) Parent Contact
4) Coach Contact
5) # of Post SRC Evals
6) Days out from sport
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Post SRC Data Collection
ItemPreseason
Baseline
Onset
of SRC
24-72 Hrs.
post SRC
7 days
post SRCUnrestricted
RTP
3, 6 and 12
months Post
SRC
Demographics X
PHQ-9 X X X X X
PedsQL X X X X X
SRC Symptoms X X X X X
RESULTS
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School Characteristics
Group EnrollmentAthletes /
AT Hour
LoAT301
[183, 661]
59.0
[48.7, 93.0]
MidAT650
[394, 966]
24.1
[22.1, 27.1]
HiAT421
[285, 538]
11.6
[6.7, 12.7]
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Demographics
SubjectsLoAT
(n = 747)
MidAT
(n = 828)
HiAT
(n = 884)N = 2459
Sex < 0.001
Female 257 (34.4) 271 (32.7) 392 (44.3) 920 (37.4)
Male 490 (65.6) 557 (67.3) 492 (55.7) 1,539 (62.6)
Grade 0.012
9 208 (27.8) 293 (35.6) 271 (30.7) 772 (31.4)
10 190 (25.4) 190 (22.9) 251 (28.4) 631 (25.7)
11 183 (24.5) 186 (22.5) 199 (22.5) 568 (23.1)
12 166 (22.2) 159 (19.2) 163 (18.4) 488 (19.8)
SRC History
Yes - Any SRC 111 (14.9) 186 (22.5) 162 (18.3) 459 (18.7) 0.001
Yes - SRC < 12 Mon. 59 (7.9) 94 (11.4) 72 (8.1) 225 (9.2) 0.026
Total Symptoms 0.0 [0.0, 1.0] 0.0 [0.0, 1.0] 0.0 [0.0, 2.0] 0.0 [0.0, 2.0] 0.001
Symptom Severity 0.0 [0.0, 1.5] 0.0 [0.0, 2.0] 0.0 [0.0, 3.0] 0.0 [0.0, 2.0] 0.001
PHQ9 score 0.0 [0.0, 2.0] 0.0 [0.0, 2.0] 1.0 [0.0, 3.0] 0.0 [0.0, 2.0] < 0.001
PedsQL 4.0 93.2 (8.2) 93.5 (8.0) 92.9 (8.0) 93.2 (8.0) 0.311
mcguine@ortho.wisc.edu
Sport Seasons
Sport SeasonsLoAT
n = 1,263
MidAT
n = 1,306
HiAT
n = 1,297
N = 3,866 (%)
Baseball 61 (4.8) 51 (3.9) 84 (6.5) 196 (5.1)
Basketball 381 (30.2) 262 (20.1) 300 (23.1) 943 (24.4)
Football 452 (35.8) 402 (30.8) 320 (24.7) 1,174 (30.4)
Ice Hockey 10 (0.8) 18 (1.4) 24 (1.9) 52 (1.3)
Soccer 48 (3.8) 166 (12.7) 121 (9.3) 335 (8.7)
Softball 41 (3.2) 62 (4.7) 47 (3.6) 150 (3.9)
Track 31 (2.5) 75 (5.7) 105 (8.1) 211 (5.5)
Volleyball 172 (13.6) 152 (11.6) 206 (15.9) 530 (13.7)
Wrestling 20 (1.6) 23 (1.8) 37 (2.9) 80 (2.1)
Other2 47 (3.7) 95 (7.3) 53 (4.1) 195 (5.0)
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Results
AE: 185,832
Subjects: 125 (128 SRCs)
Sport SRCs
Football 62
Basketball 17
Soccer 12
Volleyball 12
Ice Hockey 6
Base / Softball 4
Lacrosse 3
Wrestling 3
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Incidence of SRCs
Group SRC (%)Multi-Variate
Hazards Ratio
(95%CI)
LoAT 18 (2.4%) ref.
MidAT 46 (5.6%) 2.59 (1.03, 6.53)
HiAT 62 (7.0%) 3.33 (1.55, 7.13)
)
LOAT MIDAT HIAT
p = 0.043
p = 0.002
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Elapsed Time to Evaluation by AT
GroupHours
Median [IQR]
LoAT 24.0 [5.4, 58.0]
MidAT 0.5 [0.0, 20.0]
HiAT 0.2 [0.0, 25.0]
LOAT MIDAT HIAT
p = 0.015
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Contact With A Parent
Group n (%)
LoAT 15 (83.3)
MidAT 47 (100)
HiAT 63 (98.4)
LOAT MIDAT HIAT
p = 0.001
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Contact With The Coach
Group n (%)
LoAT 14 (82.4)
MidAT 47 (100.0)
HiAT 64 (100.0)
LOAT MIDAT HIAT
p < 0.001
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# Post-SRC Evaluations by AT
Group Median [IQR]
LoAT 2.0 [1.0, 2.8]
MidAT 3.0 [3.0, 3.0]
HiAT 4.0 [3.0, 5.0]
LOAT MIDAT HIAT
p < 0.001
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Utilized RTP Protocol
Group n (%)
LoAT 9 (50.0)
MidAT 44 (93.6)
HiAT 64 (100.0)
LOAT MIDAT HIAT
p < 0.001
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# Days Out From Sport
Group Median [IQR]
LoAT 11.5 [9.2, 14.0]
MidAT 14.0 [10.0, 18.0]
HiAT 14.0 [11.0, 23.0]
LOAT MIDAT HIAT
p < 0.001
CONCLUSIONS
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AT availability in schools was associated with various rates
of recognized SRCs and post-SRC management actions
Given the significant public health burden SRCs impose…..
Sufficient AT availability is crucial to rapidly identify, assess
and manage these injuries
What About the Health Outcomes?
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Prospective / longitudinal assessment
No impact on athletes after RTP interval for:
Symptoms
Symptom Severity
Depression
Health Related Quality of Life
Health Outcomes Reporting
-3
-2
-1
0
1
2
3
4
-10
-8
-6
-4
-2
0
2
4
6
8
10
mcguine@ortho.wisc.edu
mcguine@ortho.wisc.edu
Citations
Broglio SP, Cantu RC, Gioia GA, et al. National Athletic Trainers’ Association position
statement: management of sport concussion. J Athl Train. 2014;49(2):245–265
McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K.Unreported concussion in
high school football players: implications for prevention. Clin Sport Med. 2004;14(1):13–
17.
Meehan WP, D’Hemecourt P, Collins CL, Comstock RD. Assessment and management of
sport-related concussions in United States high schools. Am J Sports Med.
2011;39(11):2304-2310. doi:10.1177/0363546511423503
McGuine TA, Pfaller AY, Post EG, Hetzel SJ, Brooks A, Broglio SP. The influence of
athletic trainers on the incidence and management of concussions in high school athletes.
Journal of Athletic Training. 2018; Nov.doi.org/10.4085/1062-6050-209-18.
Post E, Winterstein AP, Hetzel SJ, Lutes B & McGuine TA. School and Community
Socioeconomic Status and Access to Athletic Trainer Services in Wisconsin Secondary
Schools. Journal of Athletic Training. 2018; doi.org/10.4085/1062-6050-440-17
THANK YOU!
mcguine@ortho.wisc.edu
Supplementary slides
(if needed)
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SRC Injury Definition
SRC will be defined according NATA as a: ‘‘trauma induced alteration in mental status that
may or may not involve loss of consciousness.’’ This alteration may include the rapid onset
of short-lived impairment of neurological function and may involve one or more of the
following symptoms: headache, nausea, vomiting, dizziness/balance problems, fatigue,
difficulty sleeping, drowsiness, sensitivity to light/noise, blurred vision, memory difficulty,
and difficulty concentrating.
Specifically, an injury must meet both of the following criteria:
1) Occurred as a result of participation in
interscholastic sport practice or competition.
2) Required medical attention and or treatment
by the school AT or licensed primary care
provider (MD, NP, PA etc.) before the subject
was allowed to return to sport.
SRCs will be excluded if they did not occur during interscholastic sport participation.
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Changes in PedsQL Scores
Pre-SRC to 12 Mon. Post-SRC
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Changes in PHQ-9 (Depression)
Pre-SRC to 12 Mon. Post-SRC
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Changes in Symptoms and Symptom
Severity Pre-SRC to 12 Mon. Post-SRC
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