Certified Athletic Trainers’ Use of Cervical Clinical Testing in the Diagnosis and Management of Sports-Related Concussion

in Journal of Sport Rehabilitation
View More View Less
Restricted access

Purchase article

USD  $24.95

Student 1 year online subscription

USD  $76.00

1 year online subscription

USD  $101.00

Student 2 year online subscription

USD  $144.00

2 year online subscription

USD  $192.00

Context: Despite evidence implicating cervicogenic symptoms in the development of persistent postconcussion symptoms, factors that influence utilization of cervical clinical tests to identify cervicogenic symptoms following concussion are poorly understood. Objective: Explore barriers to the utilization of cervical clinical testing in multifaceted concussion evaluation. Design: Cross-sectional. Setting: Online survey. Patients or Other Participants: A total of 122 athletic trainers (AT) (age = 42.6 [6.4] y; female = 51.6%; 52% >10 y of clinical practice; 68% master’s degree or greater; 35% treated a minimum of 15 concussions/y). Main Outcome Measure(s): Perceived importance, clinical experience, number of concussions treated, utilization of cervical clinical tests following nonspecific cervical pathology and following concussion, comfort with cervical treatment modalities following a concussion, and recommendation for cervical-specific therapy to treat persistent postconcussion symptoms. Results: Ordinal logistic regression revealed perceived importance had the strongest positive impact on AT’s likelihood of high utilization of cervical clinical testing following concussion (95% CI, .17 to .99; P = .005), while clinical experience (95% CI, −.43 to .29; P = .71) and number of concussions treated/y (95% CI, −.21 to .31; P = .71) had no bearing. Moreover, low comfort with cervical treatments following a concussion (95% CI, −2.86 to −.26; P = .018) and low utilization of cervical clinical testing following nonspecific cervical pathology (95% CI, −7.01 to −3.39; P ≤ .001) had a strong positive impact on high utilization of cervical clinical testing following concussion. Two logistic regression models demonstrated how recommendations for cervical-specific therapy in persistent post-concussion symptom patients could be predicted based on (1) cervical test utilization and (2) perceptions and clinical experience with 79% and 78%, respectively. Conclusions: Perceived importance played a major role in utilization of cervical clinical test following concussion. ATs who utilized common cervical treatments when dealing with non-concussive injuries were more likely to utilize those same treatments to treat comorbid cervical pathology following a concussion.

Cheever is with the Department of Kinesiology, College for Health, Community and Policy, The University of Texas at San Antonio, San Antonio, TX, USA. Kay is with the School of Health Professions, College of Nursing and Health Professions, The University of Southern Mississippi, Hattiesburg, MS, USA.

Cheever (kelly.cheever@utsa.edu) is corresponding author.
  • 1.

    McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin 2016. Br J Sports Med. 2017;51(11):838847. PubMed ID: 28446457

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Simpson JR. Mild traumatic brain injury and postconcussion syndrome: the new evidence base for diagnosis and treatment. J Am Acad Psychiat Law. 2011;39(1):133134.

    • Search Google Scholar
    • Export Citation
  • 3.

    Rose SC, Fischer AN, Heyer GL. How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain Inj. 2015;29(7–8):798803. PubMed ID: 25870975 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Lau BC, Kontos AP, Collins MW, et al. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011;39(11):23112318. PubMed ID: 21712482 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Cnossen MC, van der Naalt J, Spikman JM, et al. Prediction of persistent post-concussion symptoms after mild traumatic brain injury. J Neurotrama. 2018;35(22):26912698. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Sutton M, Chan V, Escobar M, et al. Neck injury comorbidity in concussion-related emergency department visits: a population-based study of sex differences across the life span. J Womens Health. 2019;28(4):473482. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Ellis MJ, McDonald PJ, Olson A, et al. Cervical spine dysfunction following pediatric sports-related head trauma. J Head Trauma Rehab. 2019;34(2):103110. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    King JA, McCrea MA, Nelson LD. Frequency of primary neck pain in mild traumatic brain injury/concussion patients. Arch Phys Med Rehab. 2020;101(1):8994. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Carmichael JP, Staton EW, Blatchford PJ, et al. Epidemiology of neck injuries accompanying sport concussionsin youth over a 13-year period in a community-based healthcare system. Int J Sports Phys Ther. 2019;14(3):334344. PubMed ID: 31681492 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Cheever K, Kawata K, Tierney RT, et al. Cervical pathology assessments to use during a concussion evaluation: a review J Athl Train. 2016;51(12):10371044. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    Leddy JJ, Baker JG, Merchant A, et al. Brain or strain? symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury. Clin J Sport Med. 2015;25(3):237242. PubMed ID: 25051194 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Inj. 2015;29(2):238248. PubMed ID: 25314613 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Reneker JC, Moughiman MC, Cook CE. The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An international Delphi study. J Sci Med Sport. 2015;18(4):366372. PubMed ID: 24933505 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Yorke AM, Littleton S, Alsalaheen BA. Concussion attitudes and beliefs, knowledge, and clinical practice: survey of physical therapists. Physical Ther. 2016;96(7):10181028. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Taylor DN, Wynd S. Survey of chiropractic clinicians on self-reported knowledge and recognition of concussion injuries. Chiropract Man Ther. 2018;26(1):18.

    • Search Google Scholar
    • Export Citation
  • 16.

    Kelly KC, Jordan EM, Joyner AB, et al. National Collegiate Athletic Association Division I athletic trainers’ concussion-management practice patterns. J Athl Train. 2014;49(5):665673. PubMed ID: 25188315 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Buckley TA, Burdette G, Kelly K. Concussion-management practice patterns of national collegiate athletic association division II and III athletic trainers: how the other half lives. J Athl Train. 2015;50(8):879888. PubMed ID: 26196701 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Paddack M, DeWolf R, Covassin T, et al. Policies, procedures, and practices regarding sport-related concussion in community college athletes. J Athl Train. 2016;51(1):8288. PubMed ID: 26765512 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Lynall RC, Laudner KG, Mihalik JP, et al. Concussion-assessment and -management techniques used by athletic trainers. J Athl Train. 2013;48(6):844850. PubMed ID: 24143906 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Covassin T, Elbin R III, Stiller-Ostrowski JL. Current Sport-Related Concussion Teaching and Clinical Practices of Sports Medicine Professionals. J Athl Train. 2009;44(4):400404. PubMed ID: 19593422 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Kilcoyne KG, Dickens JF, Svoboda SJ, et al. Reported concussion rates for three division i football programs: an evaluation of the new NCAA concussion policy. Sports Health. 2014;6(5):402405. PubMed ID: 25177415 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions preliminary findings. Am J Sports Med. 2014;42(10):24792486. PubMed ID: 25106780 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Baugh CM, Kroshus E, Stamm JM, et al. Clinical practices in collegiate concussion management. Am J Sports Med. 2016;44(6):13911399. PubMed ID: 27037282 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Moreau WJ, Nabhan DC, Walden T. Sport concussion knowledge and clinical practices: a survey of doctors of chiropractic with sports certification. J Chiropract Med. 2015;14(3):169175. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25.

    Mucha A, Trbovich A. Considerations for Diagnosis and Management of Concussion. J Orthop Sports Phys Ther. 2019;49(11):787798. PubMed ID: 31597546 doi:

  • 26.

    Collins MW, Kontos AP, Reynolds E, et al. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. 2014;22(2):235246. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Kontos A, Elbin R, Trbovich A, et al. Concussion Clinical Profiles Screening (CP Screen) tool: preliminary evidence to inform a multidisciplinary approach. Neurosurgery. 2020;87(2):348356.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Hammerle M, Swan AA, Nelson JT, et al. Retrospective review: effectiveness of cervical proprioception retraining for dizziness after mild traumatic brain injury in a military population with abnormal cervical proprioception. J Manip Physiol Ther. 2019;42(6):399406. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):12941298. PubMed ID: 24855132 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Reneker JC, Hassen A, Phillips RS, et al. Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial. Scand J Med Sci Sports. 2017;27(12):20092018. PubMed ID: 28211600 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Kennedy E, Quinn D, Tumilty S, et al. Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: a retrospective analysis. Musculoskel Sci Prac. 2017;29:9198. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    Marshall CM, Vernon H, Leddy JJ, et al. The role of the cervical spine in post-concussion syndrome. Physician Sportsmed. 2015;43(3):274284. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Langelier DM, Schneider KJ, Hurlbert J, et al. The importance of a neck exam in sport-related concussion: cervical schwannoma in post concussion syndrome. Phys Ther in Sport. 2017;25:8488. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    Gergen D. Management of mild traumatic brain injury symptoms in a 31-year-old woman using cervical manipulation and acupuncture: a case report. J Chiropr Med. 2015;14(3):220224. PubMed ID: 26778936 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35.

    Feddermann-Demont N, Echemendia RJ, Schneider KJ, et al. What domains of clinical function should be assessed after sport-related concussion? A systematic review. Br J Sports Med. 2017;51(11):903918. PubMed ID: 29098983 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Rebbeck T, Evans K, Elliott JM. Concussion in combination with whiplash-associated disorder may be missed in primary care: key recommendations for assessment and management. J Orthopaed Sports Phys Ther. 2019;49(11):819828. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 419 419 141
Full Text Views 10 10 5
PDF Downloads 16 16 2