Sports Medicine Research: In the Lab & In the Field: Athletic Trainers and Physicians Are Under Pressure to Release Concussed Athletes Prematurely (Sports Med Res)
Monday, September 14, 2015

Athletic Trainers and Physicians Are Under Pressure to Release Concussed Athletes Prematurely

Pressure on sports medicine clinicians to prematurely return collegiate athletes to play after concussion

Kroshus E, Baugh CM, Daneshvar DH, Stamm JM, Laursen RM, Austin SB. J Athl Train 2015; 50(6) ahead of print.

Take Home Message: More than half of the sports medicine staff experience pressure from coaches and athletes to release athletes prematurely to play following a concussion.

Concussions are sometimes referred to as the “invisible injury” for many reasons (there is no structural damage on imaging reports and small deficits are not always easily detected with the current assessment tools). This creates an environment, where the athlete or coach may believe that the concussed athlete is ready to return to play and may pressure the medical professional to return the athlete to play prematurely. Therefore, the authors utilized a web-based survey for clinicians who provide care to US collegiate sports teams to quantify the extent they experienced pressure to prematurely clear athletes for participation after a concussion. Seven hundred and eighty-nine athletic trainers and 111 team physicians (from 530 institutions) completed the survey. The survey was composed of 2 main types of questions. First, participants answered demographic type questions (their sex, position in the sports medicine team, number of years working on a sports medicine team, NCAA division, and sex/sport of the team or teams for which they provide care, and whether the heads of their department reported to the athletic department, medical institution, or another entity). The authors also assessed the extent to which a clinician agreed with statements about having experienced pressure from clinicians, coaches, or the athletes themselves to prematurely release an athlete following a concussion. Across all respondents 64% agreed that they experienced pressure from athletes to clear them following a concussion. Fifty-four percent of respondents agreed that they had pressure from coaches and 6.6% agreed they had pressure from other clinicians. Athletic trainers (55%) were more likely than physicians (41%) to experience pressure from coaches. Respondents reported greater pressure from coaches when their departments were under the athletic department’s supervision (54%) rather than a medical institution (40%). Athletic trainers reported less pressure from athletes and coaches in Division III compared with Division I. Female athletic trainers (61%) reported greater pressure from coaches than males (49%), and Female physicians reported greater pressure from other physicians than males.

The authors exemplified that there is pressure on medical professionals to return an athlete to play prematurely. Over half of the clinicians reported experiencing this pressure. Though, the frequency of the pressure and the number of times an athlete was released prematurely is unknown, this is still an alarming response. Another resonating finding was that medical professionals that report to athletic departments experience greater pressure from coaches than those who work under a medical institution, which suggest that a sports medicine team functioning under a medical institution seems to be in the better interest of the patient. Furthermore, it was distressing to see that out of the 530 institutions only 63 institutions were reported to be functioning under the medical supervisory structure. Another school characteristic such as division of school seemed to be strongly predictive, where respondents at a Division I reported the most pressure. This may be due to higher level of competition, stronger athletic identity, and desire to be part of a team. Additionally, female athletic trainers reported greater pressure from coaches compared with males, which suggests coaches feel females are less qualified or more easily intimidated compared to males. This study illustrates the importance for identifying factors associated with variability of pressure on sports medicine professionals to release concussed patients prematurely, and accentuates the need for open communication, and more concussion education among supervisors, coaches, and athletes. Furthermore, in a setting where coaches and athletes are often focused on today it is vital for sports medicine clinicians to be thinking about our patient’s long-term health and safety.

Questions for Discussion: Do you work under a medical supervisory system? Do you feel pressure from other sources not investigated by the authors? How do you handle pressure to return an athlete to play early?

Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban

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Kroshus E, Baugh CM, Daneshvar DH, Stamm JM, Laursen RM, & Austin SB (2015). Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion. Journal of athletic training PMID: 26207440

6 comments:

Mark Colapietro said...

Working in the high school setting and reporting to the athletic department, another source of pressure that athletic trainers receive pressure from in clearing an athlete to play following a concussion is from parents. Parents of high school athletes sometimes get caught up in the possibility of their child receiving a scholarship for college based on their athletic ability, and fail to keep the long-term health of their child in perspective. They sometimes even become too invested in their child's successes and fail to look out for their safety. It could be the lack of information parents have on concussions and difficulty to recognize concussion like symptoms. I feel the recognition and knowledge of concussions is spreading to parents and coaches through the practice of having parents complete online concussion training programs and concussion information sessions for teachers and parents.
As with handling pressure to return a student from a concussion, I typically rely on strict protocols in bringing athletes back and reminding myself of the serious consequences that could occur if I were to allow an athlete to return to play before being fully healed. If the athlete, parent, or coach does not understand my reasoning, I am always open with them on my reasoning to hold an athlete back by giving them information or having a constructive conversation with the party I am addressing.
One question I do have is if the above study looked at the responses to the answers in relation to years of experience? As a young clinician, I feel coaches and parents would not give the same amount of respect to a young clinician compared to an older clinician.

Jeffrey Driban said...

Mark:
Thanks for the great insights. Yes, the authors looked at years of experience and found that clinicians with more experience tended to report less pressure - supporting your hypothesis. The authors noted that " This difference in pressure experienced may have reflected less sensitivity to pressure rather than any
objective difference in the pressure delivered."

Candace Bernitt said...

I agree with Mark in that parents seem to put pressure on athletic trainers and other health care professionals to return their children to play. As a new clinician, it can be difficult to develop a trusting relationship with parents. However, at the high school that I work at we hold educational concussion meetings at the beginning of each season that are mandatory for parents and athletes. At these meetings, a video is shown that focuses on the etiology and prevalence of concussion, as well as management and consequences of improper care. I believe that these meetings help parents understand more about the importance of treating concussions and it brings to their attention the repercussions that can occur if mistreated.
Furthermore, I feel that it is important to communicate with physicians regarding concussion protocols. It is beneficial to be in agreement over this matter as to avoid any discrepancies with return to play decisions. If a parent is being told the same thing from more than one health care professional they are probably more likely to accept the decision.

Stephan Bodkin said...

I agree Candace that early education to the parents can help future encounters. I believe these educational meetings should be mandatory for every student athlete (and parents) every year, with the drastic growth of current research and management protocols. Having the parents educated about exact the etiology, mechanisms, and possible consequences can stress the importance of proper care and therefore possibly decrease pressure on the AT. I have noticed a shift within the age of the athlete as well. I do believe that implementing and enforcing these protocols at an earlier age, will allow for greater acceptance for secondary school parents. Great article!

Kyle Murray said...

I agree with the idea that there is pressure from multiple sources to release these athletes earlier following a concussion. I think that it would also be interesting to look at if the athletes themselves both pressure healthcare providers or feel like they are being pressured by coaches or parents as well. It is one thing to say that parents and coaches are pushing things but I feel like we should also be taking the athlete's own feelings about their physical well-being into account as one of the pressures that we face. I also think that it would be interesting to identify clear goals from all of these parties with regards to the management of concussion and to see how they differ.

Jane McDevitt said...

There are some great points brought up. There is obviously a concern at the high school level that athletic trainers could feel pressured as well, and I wonder if it could be due to the same reason as the D1 athletic trainers, that they work under the athletic department, and not a medical supervisory system. Athletic trainers should have physician working orders that states what the athletic trainers' practicing protocol should be; however, if some of those medical policies are instituted from the school or athletic department and not by a medical advisory system the athletic trainer may be missing out on the necessary and up to date tools that would be necessary for proper concussion diagnosis and return to play. I agree, education is necessary, but if there is pressure to return to play then we are not educating properly, because a brain injury should be taken seriously. Education is certainly the key, but we need to figure out what is the best way of distributing the information so parents, coaches, and players so they have a full understanding of concussion injuries.

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