A Look into Concussion Protocols

Posted March 15, 2017

Nicole T. Wasylyk

By Nicole T. Wasylyk, MSEd, LAT, ATC

Preventing, identifying and managing sport-related concussions (SRC) continues to be a challenge for both healthcare professionals and for patients. The complexity in management of SRC may be mitigated by adopting solid policies and procedures to follow for those involved with concussion care. Best practice for concussion management encourages all high schools, colleges, club and professional sports to have policies in place regarding SRCs.

Both the National Hockey League (NHL) and National Football League (NFL) have accepted policies1,2 with the NHL adopting a new mandatory protocol this season. The purpose of the protocols is to educate players and provide guidelines for identifying and managing sports-related concussions. It has been well publicized that both the NHL and NFL face litigation from former players accusing the leagues of failing to protect them from concussions and head injuries. They also allege the withholding of information about long-term effects of concussions.3,4 These new protocols may achieve improved player education, prevention and recognition of concussion.

At their core the protocols are very similar; the NHL and NFL reference the Zurich II Consensus Statement from 2012 to define concussion as a “brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.”5 The NHL’s protocol specifically states that all players must watch an educational video and received a brochure of the information prior to the first day of training camp. All players are also required to complete baseline concussion testing, a well-adopted best practice for all contact sport athletes. Players complete both the SCAT3 and ImPACT® Test, core components of baseline testing.

The protocols both take into account thoughtful details regarding baseline and follow-up concussion testing. For example, they recognize the importance of an appropriate baseline testing setting.  Baseline testing environment and timing of the test (not immediately after physical exertion) should be considered carefully.  It is crucial for these tests to be completed in an environment where a player has minimal distractions to ensure validity of these tests.

As both protocols describe baseline testing, they also describe recognition of sports-related concussion during game play and on-field management. Signs and symptoms of concussion are mentioned in detail along with the way each league monitors for concussions. During gameplay, the NHL utilizes 2 types of spotters or individuals who monitor game play for potential athletes who may have sustained a head injury.

The first type is a Central League Spotter described as an Athletic Trainer (AT) or athletic therapist who observes the games via multiple live game feeds in the NHL offices. The second is an In-Arena League Spotter described as an Off-Ice Official who observes the game live in the arena. If either spotter suspects a player has sustained a concussion the player is then taken off ice and assessed by the club’s medical personal as described in the protocol. In contrast, the NFL only describes a Booth Athletic Trainer; this individual serves as the spotter similar to the Central League Spotter for the NHL.

If an NFL player is suspected of having a concussion during a game, they are removed from play and assessed as described by the “Madden Rule.” This rule states that the player must be removed from the field and evaluated in the locker room area by medical personal. If medical staff concludes a concussion was sustained that player is not permitted to return to play the same day. If no concussion is suspected, then video of the game play must be reviewed to remove any doubt of head injury prior to allowing the player to return to participation. The NHL describes assessment similar to the NFL’s “Madden Rule.” Return to play progression is also outlined in both protocols and both leagues encourage a multidisciplinary team approach to treatment. The medical teams are comprised of either a neurotrauma consultant or neuropsychologist along with the team medical doctors and ATs.

These concussion protocols serve as a comprehensive approach to education, diagnosis and management of sports related concussions. It is important that a transparent policy is adopted as a part of best practice so players, coaches, medical staff and officials understand not only the actions to take to protect athletes but expectations surrounding concussion recognition, management and return to sport.











About the Author

Nicole Wasylyk works as an Athletic Trainer in a physician practice at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire. Prior to DHMC she resided in Madison, Wisconsin and was an Athletic Trainer in a physician practice at Meriter-Unity Point Health. Wasylyk obtained her Bachelor of Science in Athletic Training from Boston University and Masters of Science in Education from Old Dominion University. She has completed a residency program for healthcare providers who extend the services of a physician at UW Health. Wasylyk also obtained her orthopedic technician certification. Her professional interests include injury surveillance and prevention, standardization of best practices and patient reported outcomes collection. 




Sports Dentistry: Why is it Critical to have Dentists Part of the Pre-participation Examination?

Posted March 13, 2017

Kurt Andrews

By Kurt Andrews M.S., ATC, PES, CES

It’s not even day 1 of the new season yet. It’s the first time the lights have been turned on in the athletic training facility since an early exit in playoffs gave rise to a dramatic ending and unexpected offseason. Memories of the holidays remain fresh but need to be stored in the long-term memory bank as it is now time to get things prepared for the upcoming season.

The offseason has brought many changes within the organization as old faces have gone on to new challenges where new and old faces have assumed new positions. In preparation for the upcoming physicals, it’s encouraging to know that the medical staff has remained the same, thus ensuring continuity and efficiency at the doctor’s office.

All stations are set, the orthopedic doctors are set to do their exams, the podiatrist is confirmed to come down and scan everyone and the primary care providers are all set for electrocardiogram (EKG) testing. The doctor’s office has hired nurses to run all the tests for general health, the ophthalmologist is ready to do the annual eye exam and the chiropractors are coming by to do spinal evaluations. The dietician is ready to sit down and do one on one evaluations with all the athletes, the neuropsychologist is ready to impact test everyone and the performance staff is ready to put the team through physical test to get an understanding of the performance perspective. Amongst the organized chaos in the doctor’s office is a familiar face, one that doesn’t get much sideline attention during games.  But, one who is a crucial component of the sports medicine staff, the team dentist.

Sports dentistry is a new area of sports medicine specialization, not so much in terms of utilization amongst the athletes and athletic departments, but more so in its utilization in prevention principles of potential oral and facial injuries involved in the related sports. Sports dentistry also focuses on the prevention of any oral diseases and manifestations that may occur along with the maintenance and treatment of oral and facial injuries.

Dental trauma in sports is the major link between sports and dentistry, thus making dentists a necessity at pre-participation examination (PPE). During the team physicals the team dentist conducts oral health screenings and is involved with the fabrication of custom made mouth guards for certain sports such as  football, hockey, lacrosse, basketball or wrestling. They also make themselves available for any sort of emergency care or dental procedures that need to take place before the season starts preventing athletes from missing time during the season. Dentists should also be playing an active role in educating the public and athletes on the use of protective equipment for sporting activities not only to prevent injuries but also to reduce healthcare costs (Ramagoni et al., 2014).

Many sports related traumatic dental injuries are preventable with the use of appropriate, properly fitted and protective athletic equipment. These include but are not limited to helmets, facemasks and custom mouth guards. The National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc. estimates that during the season of play athletes have a 10 percent chance of sustaining an injury to the face or mouth (Ramagoni et al., 2014). The most common orofacial sports related injuries include soft tissue injury and hard tissue injury including those to the teeth and facial bones such as tooth intrusions, luxations, crown/root fractures, complete avulsions and dental facial fractures (Saini, 2011).

The front teeth are the most affected by dental trauma with the maxillary central and lateral incisors being the most commonly injured teeth. The most common tooth injury is an uncomplicated crown fracture (Soares et al., 2014). Most of the time these injuries occur from a direct hit by a ball or from player to player contact. On the rare occurrence, while on the road for a game, it can be critical for an Athletic Trainer to have the team dentist available via phone or text to assist in the trouble shooting of a problem and come up with a short-term solution until the team comes back home.

By having a team or university dentist involved during the entrance physical, this professional can help facilitate the custom fabrication of mouth guards for the athletes involved in contact sports. These custom made mouth guards are superior to the stock or “boil and bite” mouth guards because of their adaptability and retention but are also believed to interfere the least with breathing and speech. Mouth guards should be worn when there is a possibility of any sort of physical contact with an opponent because they can help to prevent injuries to the teeth, lips, gingiva, tongue and mucosa. They cushion the blows that could cause jaw fractures, dislocations and trauma to the temporomandibular joint (Saini, 2011). According to the American Dental Association, the use of faceguards and mouth protectors prevent more than 200,000 orofacial injuries in football annually (Saini, 2011).

During the Athens Olympics in 2004, dental services were the second most utilized service in the Olympic village behind physiotherapy. The most common procedures were dental fillings (313 permanent and 31 temporary), root canals, pericoronitis treatment and mouthguard fabrications. The entrance physical is a perfect place for the dentist to be involved so every athlete can have a dental assessment. This will ensure that their oral health status is verified and cleared and any issues that may come up can be handled in the preseason.

In a study from 2003 to 2006, professional soccer players from the Spanish team Barcelona were compared with students of Dentistry and Medicine from the University of Barcelona. The researchers found that the average active dental cavity was significantly higher among professional soccer players compared to the dental student (Soares et al., 2014). What this shows is that the students practiced what they preached and were more willing to participate in dental hygiene practices, but that’s because they are familiar with them. The take home message from a study like this is that these dental issues are more widely spread amongst  athletes and the team dentist needs to establish a program encouraging oral health to the athletes of a university, college, professional or amateur teams.

A different study looking at 400 medical records of 353 amateur and 47 professional soccer players, found the results of poor oral health far worse for amateurs than the pros. In the amateur athletes, they found 283 cavity lesions (71 percent), 109 root canals (27 percent), 33 abscesses (9 percent) and 78 tooth extractions (22 percent). When compared to the professional athletes, they found 32 cavity lesions (68 percent), 11 root canals (23 percent), no cases of abscesses (0 percent) and 24 tooth extractions (51 percent) (Soares et al., 2014).

Swimmers have also been found to have a higher than normal tooth enamel decay. Researchers have found that swimming athletes are affected with biocorrosion of enamel because of the chlorine used to keep the pools clean; the acidic water in contact with the teeth causes irreversible tooth structure wear especially to the anterior teeth (Soares et al., 2014).

It is easy to understand now how important it is to have a dentist involved within the sports medicine team, and why they could and should be involved during the PPE or entrance physical exam. The duty of the sports dentist is to work alongside the athletic training staff to ensure the oral healthcare of the athletes, identify any individual risks, and develop prevention plans so that the athletes can avoid any major dental issues. The inclusion of a dentist to your sports medicine program can be a major component of your injury prevention model.

Dr. Padilla’s (Team Dentist for LA Galaxy) Top Tips for Dental Health

1. Regular scheduled dental exams and professional cleanings.

2. Be proactive rather than reactive. Complete any necessary treatment in a timely manner. Don’t put off treatment because it doesn’t hurt yet. This will insure minimal treatment performed.

3. Have good home dental hygiene care. Brush and floss at least twice a day.

4. Diet can contribute to dental problems. Limit excessive acidic drinks like sodas, fruit juices and sports drinks. These acidic drinks may dissolve tooth enamel which may contribute to tooth erosion and cavities. Rinse and hydrate with water after taking these acidic drinks.

5. Avoid smokeless tobacco, which can cause periodontal and oral cancer complications.

6. Wear custom made athletic mouth guards in competing in trauma related sports.


Ramagoni, N. K., Singamaneni, V. K., Rao, S. R., & Karthikeyan, J. (2014). Sports dentistry: A review. Journal of International Society of Preventive & Community Dentistry4(Suppl 3), S139.

Saini, R. (2011). Sports dentistry. National journal of maxillofacial surgery2(2), 129.

Soares, P. V., Tolentino, A. B., Machado, A. C., Dias, R. B., & Coto, N. P. (2014). Sports dentistry: a perspective for the future. Revista Brasileira de Educação Física e Esporte28(2), 351-358.

About the Author

Kurt Andrews, originally from the metro Detroit area, graduated with his bachelor’s degree in Exercise Science in 2008 from Oakland University. He has been a BOC Certified Athletic Trainer since 2011 where he earned his master’s in Athletic Training from the entry level master’s program at the University of Arkansas. He currently is in his fifth year as an assistant Athletic Trainer for the Major League Soccer (MLS) club LA Galaxy. He currently holds memberships with NATA, CATA and PSATS where he serves on the sponsorship, continuing education and research committees and was presently serving as the Western Conference senator.


In-Depth Look: Head Athletic Therapist for the Kingston Frontenacs Hockey Club

Posted March 7, 2017

Ryan Bennett, BHED, Dip SIM, CAT(C), ATC, CSCS is Head Athletic Therapist for Kingston Frontenacs Hockey Club, a major junior hockey team in the Ontario Hockey League. He has worked for 12 seasons in this league.

Describe your work setting:

I work for a major junior hockey team in the Ontario Hockey League. Currently, there are more players who go to the National Hockey League from our league than any other junior league in the world. It is a field setting, but I have a clinic and office I use for rehab and treatments.

How long have you worked in this setting?

I am in my 12th season in this league. Before that, I worked 4 years in professional hockey, mainly in the American Hockey League.

Describe your typical day:

There isn’t really a typical day for me as we play or practice at different times depending whether it's a weekday or weekend. Typically, we play 2-3 days a week, have 1 day off where only injured players report and practice each day the rest of the week. Our season starts with training camp in early September. The end of season is late March with a possibility of 9 weeks of playoffs. We play 34 home games and 34 road regular season games.

A typical practice day has me arriving around 8:45am to prepare for our older, non-high school players' arrival at 9:30am. They workout or receive necessary treatment until 11:00am. Once they have left for lunch, the equipment manager and I work on laundry, tidying the dressing room and gym and getting the bench ready for afternoon practice. Players arrive back around 1:00pm, and I work on any pre-practice stretching, taping, wrapping and treatment. Practice starts around 2:15pm, and I watch for issues and injuries from the bench.

When practice ends at 4:00pm, I supervise the high school players' workout and perform any other stretching or necessary treatments. The players leave around 5:00pm. At this time, the equipment manager and I work on laundry, and clean and prepare the dressing room and gym for the next day. I typically leave the rink at 6:00pm.

Game days have a similar morning with a few hours break in the middle of the day. I arrive back at 3:00pm to prepare. The players arrive between 4:00pm-5:00pm. Games usually start at 7:00pm, and I get home after the game and cleanup, between 11:00pm and 12:00am.

What do you like about your position?

I grew up playing hockey so I've always loved the team atmosphere, it's like a second family. The feeling of winning, especially big games and championships, is second to none. Treating elite and motivated athletes twice a day allows me to see quick improvements. It's very rewarding to get them playing ahead of doctors' estimates. Hockey has also allowed me to travel all over the province, country and world with my junior teams and international programs.

What do you dislike about your position?

I've missed many events including weddings, funerals, birthdays and celebrations of friends and family which is unfortunate. My schedule isn't very flexible and doesn't allow for any missed or sick days. I've missed only 2 games over 12 years, for my daughter's birth. It's also tough being away from my family during long days and long road trips. However, things like FaceTime help and having summers off goes a long way to make up for it.

What advice do you have about your practice setting for a young AT looking at this setting?

For those looking to work as an athletic therapist or Athletic Trainer (AT) with an elite sports team, I would suggest volunteering as an assistant to make sure you understand the huge level of commitment required to do a good job. Also, work with as many different ATs and other healthcare providers as possible. The skills and connections gained from other healthcare professionals will prove invaluable. Finally, nobody gets into this field for the hours or money so make sure you're learning and enjoying your job every single day. This is what I do and I haven't worked a day in my life!


Exercise Associated Muscle Cramps

Posted March 6, 2017

By Michelle Snow, MA, AT, CSCS

Muscle cramps are often associated with heat and dehydration. A 2003 study looked at the number of heat related illnesses during a football season. Seventy-three percent of these illnesses were related to muscle cramping.1  Dehydration has long been blamed as the cause of exercise associated muscle cramps (EAMC). The most common theory places blame on salty sweat removing electrolytes from the body.

However, if EAMCs are heat and dehydration related, why do people experience cramping during cold weather events or while swimming in cold water? And, why does stretching almost immediately relieve the EAMC?

Unfortunately, to date, very little evidence and research has found a cause for EAMC. Two theories have been developed to help explain what may contribute to cramping, the dehydration and electrolyte imbalance theory and the altered neuromuscular control theory.

Initially, it was believed fluid and electrolyte disturbances may cause EAMC. This theory hypothesized that sweating caused a loss of fluid and electrolytes. This would lead to contraction of the interstitial space and a loss of interstitial volume. The increase in surrounding ionic concentrations and mechanical deformation of the nerve endings leads to a hyper-excitable motor nerve and a spontaneous contraction.

The theory was based on observation that athletes who experienced EAMC would often have significant fluid and electrolyte losses at the time of the cramp.4 However, it has been shown that losses in fluids and electrolytes, plasma, blood volume and body weight are similar in individuals who experience EAMC and those who do not experience cramping. Even when given a sports drink that reflected individual fluid losses, approximately seventy percent of participants still experienced EAMC.2

Due to these discrepancies, the second theory regarding a neuromuscular etiology has the strongest support from current research. This theory hypothesizes that neuromuscular fatigue alters the reflex control mechanisms of both the muscle spindle and golgi tendon organ, eliciting muscle cramping.4

The muscle spindle responds to length changes in the muscle. As length increases, the muscle spindle increases impulses to the agonist muscle to contract and decreases impulses to the antagonist muscle so it relaxes. The golgi tendon responds to length changes in the tendon and causes the agonist muscle to relax. Both work together to protect the muscle from over stretching. However, with fatigue, it has been noted that the muscle spindle activity increases while the golgi tendon activity decreases.2 This may explain why muscle cramps occur later in activity once the muscle has fatigued.

In most studies, fatigue has been the most common contributing factor to muscle cramping. This may be caused by an increase in exercise intensity and/or duration. It has also been found that those who have a history of EAMC are more likely to cramp again during other bouts of exercise. Current injury or previous history of injury may also play a role in EAMC. And, it has been found that male athletes are more likely to cramp than female athletes due to the greater proportion of fast-twitch fibers4.

The most effective treatment for acute fatigue-induced muscle cramps is static stretching of the affected muscle. It is thought that static stretching activates the golgi tendon organ by increasing tension in the tendon, causing increased afferent reflex inhibition.4  While the old method of using pickle juice may not change the blood plasma concentrations of electrolytes, it has been found that the acetic acid in pickle juice may trigger a reflex that increases neurotransmitter inhibition to cramping muscles.3 This has been found to effectively shorten the duration of EAMC.

However, it may not be an effective treatment for athletes who develop stomach duress or acid reflux after consumption. Even though there is little evidence to support the dehydration-electrolyte theory, it is still recommended that athletes remain hydrated to prevent heat illness. It is important to continue to recommend athletes to consume enough fluid so that not more than two percent of body weight loss occurs due to perspiration.

Other treatments have been recommended, however, little research has been completed to determine how effective they may be. Plyometric exercises and eccentric exercise may be incorporated for athletes who chronically experience muscle cramps. One study looked at strengthening the gluteus medius to help an athlete who struggled with hamstring muscle cramping. With the agonistic relationship of the hamstring and the gluteus medius, it was proposed that the weak glut might increase the amount of work the hamstring needed to do,  fatiguing the hamstring more quickly. The athlete targeted in this study was able to complete 3 triathlons without EAMC following 3 weeks of the targeted strengthening.4

Further research is needed to explain what causes exercise associated muscle cramps. Fatigue plays a significant role in muscle cramping. However, it does not explain how some athletes experience cramps, while others do not. The most effective treatment is static stretching of the affected muscle.


1. Cooper, E. R., Ferrara, M. S., Broglio, S. P. (2006). Exertional Heat Illness and Environmental Conditions during a Single Football Season in the Southeast. Journal of Athletic Training, vol. 41, 332-336.

2. Miller, Kevin. The Neurological Evidence for Muscle Cramping. NATA Symposium, June 2011, New Orleans Convention Center, New Orleans, LA. Conference Presentation.

3. Miller, K. C., Mack, G. W., Knight, K. L., Hopkins, J. T., Draper, D. O., Fields, P. J., Hunter, I. (2010). Reflex Inhibition of Electrically Induced Muscle Cramps in Hypohydrated Humans. Medicine and Science in Sports and Exercise, vol. 42, no. 5, 953-961.

4. Nelson, N. L., Churilla, J. R. (2016). A Narrative Review of Exercise-Associated Muscle Cramps: Factors that Contribute to Neuromuscular Fatigue and Management Implications. Muscle and Nerve, vol. 54, no. 2, 177-185.





Cardiac Screening in High School and College Aged Athletes

Beth Druvenga

Posted March 3, 2017

By Beth Druvenga, M.S. Ed, LAT, ATC

The inherent risk of injury when participating in some form of competitive athletics is widely accepted. Athletes suffer sprains, strains, concussions, fractures, contusions and lacerations to name a few injuries. A risk not so widely accepted is the risk of sudden cardiac arrest (SCA) or sudden cardiac death (SCD).

We have all seen the stories on the news or read the articles: A young athlete gone too soon. Athletes are in shape and generally in good health; they are not supposed to be participating one minute and unresponsive the next. As an empathetic, reasoning and rational culture, we cannot accept young lives being taken unexpectedly during athletic participation. But, it does happen. As an Athletic Trainer (AT) there is a list of potentially fatal events which may occur every day. I have to take a time out before games to internally review my emergency action plan (EAP), to prepare myself for the worst.

According to a 2011 study by Harmon et al., “SCD is the leading medical cause of death in NCAA athletes, is the leading cause of death during sport and exercise, and occurs at a much higher rate than previously accepted.”1 Hypertrophic cardiomyopathy and coronary artery anomalies account for 53 percent of all sudden cardiac deaths.2 Universally, professionals in the cardiac and sports medicine world alike have a common goal of preventing sudden cardiac death in athletes.4

To help prevent SCD, scientists and researchers have encouraged cardiac screening as a tool to detect underlying cardiac disorders and take the necessary steps for prevention. In fact, the Fédération Internationale de Football Association or International Federation of Association Football (FIFA) and the Union of European Football Associations (UEFA) have made cardiac screening mandatory before competition, and the International Olympic Committee encourages it as best practice.3 However, in the United States, only the National Basketball Association (NBA) mandates electrocardiograms (ECGs) or echocardiography annually.2

In Italy and Israel, it is required as part of a pre-participation examination (PPE) to have a cardiac screening.4 While in the United States a PPE involves a medical questionnaire and physical examination by a healthcare professional.2 And although the American Heart Association (AHA) supports pre-participation cardiovascular screening, it also acknowledges that it is not practical in mass context or nationwide mandate, due to the cost being an estimated 2 billion dollars per annum. Thus, the question remains. How do we move forward?

Until a nationwide, homogenous standard for cardiovascular screening is established for all high school and college aged athletes, take a look at some ways to combat SCA and SCD.

- Review your PPE questionnaire to confirm it includes questions the AHA supports for detection of potential cardiovascular disorders. Verify that these exams are being performed by a physician, nurse practitioner or physician assistant; someone who is trained and comfortable with detection of cardiovascular problems. According to the AHA, there is an increasing trend of states allowing chiropractors and naturopaths to perform PPE screenings, though they lack the cardiovascular screening training.2

- Review your facility’s EAP with not only your sports medicine staff but with people in the building who will be present when the EAP is put in to action. I am certain there are coaches and administrators who receive their EAPs but fail to read them and are not familiar enough to confidently put them into action.

- Get an automated external defibrillator (AED). I repeat, get an AED! Early defibrillation is essential during SDA to increase the chances of survival. If your school doesn’t have an AED, there are many grants and resources available to assist you in acquiring one.

- Consider providing cardiac screening for your school. There are many companies that perform cardiac screening, so reach out to your community and see what is out there. The most basic cardiac screening consists of a 12-electrode ECG which analyzes resting heart rhythm. This can help detect cardiac anomalies which may require further testing.

You, as an AT, are the best resource. Advocate for your athletes. I know ATs who have lost a student athlete to SCD. My hometown lost a student athlete to SCD during a wrestling tournament a little over a year ago. It all begins with YOU. Do your research to help prevent SCD and protect your athletes. Below are resources for cardiac screening and resources for AED grants, and I urge you to utilize them.

Cardiac Screening Resources

Parent Heart Watch: https://parentheartwatch.org/events/

AED Resources

Sudden Cardiac Arrest Foundation: www.sca-aware.org/school/funding-sources


1. Harmon, K., Asif, I., Klossner, D., & Drezner, J. (2011). Incidence of Sudden Cardiac Death in National Collegiate Athletic Association Athletes. Circulation, 1594-1600.

2. Maron, B., Thompson, P., Ackerman, M., Balady, G., Berger, S., Cohen, D., et al. (2007). Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update. Circulation, 1643-1655.

3. Schmied, C., & Borjesson, M. (2013). Sudden cardiac death in athletes. Journal of Internal Medicine, 93-103.

4. Steinvil, A., Chundadze, T., Zeltser, D., Rogowski, O., Halkin, A., Galily, Y., et al. (2011). Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death: Proven Fact or Wishful Thinking? Journal of the American College of Cardiology, 1291-1296.

About the Author

Beth Druvenga is an Athletic Trainer currently living in northern Virginia. She has experience working in both a collegiate and high school setting. Druvenga is originally from Iowa where she earned her Bachelor of Arts degree in Athletic Training from Central College in 2012. She graduated from Old Dominion University in 2014 with a Master of Science in Education. Her professional interests include patient-reported outcomes, psychology of injury and rehabilitation as well as using yoga to increase flexibility.





Make a Life-Saving Decision: Become an Organ and Tissue Donor

Posted February 23, 2017

By Mackenzie Simmons, ATC

National Donor Day was February 14th, and the main purpose is to raise awareness for organ, eye, tissue, marrow, platelet and blood donation. In addition, the day aims to recognize those who have donated organs, have received a donation or are currently waiting for an organ transplant. It is important to know that all people, regardless of age or medical history, are eligible to become a potential donor. It is also essential to encourage all members of the community to become organ donors because transplant success tends to be better when organs are matched between persons of the same ethnic or racial background.

Here are some important statistics about organ donation:

1. There are currently 119,000 people who are awaiting lifesaving organ transplants

2. In the United States, 8,000 deaths occur every year due to organs not being donated in time

3. By becoming a donor, you can:

- Save up to 8 lives if you donate your organs

- Restore eyesight in 2 people if you donate your cornea

- Heal up to 75 people if you donate your tissue

4. 683,000 transplants have occurred since 1988

5. In 2016, 33,600 transplants took place; this is an 8.5% increase from 2015

There are several ways for you to donate. First and foremost, you can register to be a donor, which can be done online or at your local DMV. Another way to support organ donation is to offer financial support to Donate Life America to help save lives in future.

One of the best ways to raise money for Donate Life America is to create a fundraising page, in memory of a loved one or in honor of a life event. Educating others on the importance of organ donation can help bring awareness to the issue; educational resources are available on www.donatelife.net. Lastly, as an individual, you can take steps to avoid the need for an organ transplant or donation. By visiting your doctor once a year, exercising regularly and eating a healthy diet, you are taking steps to reduce the chances of being on the organ donation list.




2017 NFL Pro Bowl Concussion Symposium and Health Screening

Desi Rotenberg

Posted February 21, 2017

By Desi Rotenberg, MS, ATC

The 2017 NFL Pro Bowl is a tradition that stems back to its inception in 1938. While the teams have changed drastically since then, the NFL Pro Bowl has become a tradition of competitive fun and entertainment for players, NFL front offices and fans. 2017 was the first year since 1980 (minus 2009) that the game was held within the continental United States. This venue change hoped to bring more fans, more attention and enhanced exposure of the game itself.

One of the attention grabbers for me during the Pro Bowl weekend occurred off the field. This year, The University of Central Florida (UCF) hosted the 2017 Pro Bowl Concussion Symposium and Health Screening. The purpose of this symposium was two-fold. First, retired NFL players were invited to partake in health screenings for free to help identify any neurological, cardiovascular or other issues plaguing them due to their playing time in the league. Second, the NFL Players Association partnered with the UCF Psychology Department to present all of the latest research and treatment options related to concussions in the world of sports, and more specifically, the game of football.

Here are a few of the highlights:

Following the U.S. Supreme Court settlement regarding previous NFL players and head injuries, the science has gained a significant amount of traction. As new empirical data emerges and technology continues to develop, more funding is becoming available to allow athletes to have increased access to neurological assessment and professional evaluation following head trauma. Interestingly, the Supreme Court settlement included a 65-year plan that will give retired NFL players and their families financial support if they experience symptoms of amyotrophic lateral sclerosis (ALS), dementia or any other life-altering behaviors or symptoms that may arise secondary to traumatic brain injury.

Furthermore, baseline testing is being made available to all retired NFL players and will be done immediately upon retirement. This will allow the players’ medical teams to identify any behavioral, cognitive or neurological changes that may arise over the remainder of the individual’s life.

The overarching goal is to have every college, high school and middle school offer some form of baseline testing in at least one sport for all student athletes. We are slowly, but surely, making our way towards that goal. However, there still remains room for improvement when it comes to baseline testing.

The areas of deficiency that were identified was a lack of baseline testing within recreational sports and ease of administration within middle schools and high schools. If we want to ensure the safety of all athletes, we must do what we can to have concussion education, a concussion protocol and return to play protocol in place.

At the academic levels, we must also ensure that we have a return to learn protocol in place. The question that acts as a defense for medical professionals responsible for the return to play decision is, “If you cannot learn new information, should you be returning to play?”

Emerging Technology

To this point, there are 2 questions that remain: 1) How do we diagnose Chronic Traumatic Encephalopathy prior to death, and 2) How do we avoid the high cost of imaging when it comes to concussion diagnostics?

There is by no means an answer to the first question as of yet, but I am hopeful due to the emergence of Diffuse Tensor Imaging (DTI). DTI has been around for roughly 20 years and has been mainly used in the diagnosis of strokes and other ischemic disorders of the brain.1 Within the past 10 years, research has shown that DTI can also be used to assess the integrity of the white matter in the brain.2 The goal of physicians at the symposium was to make DTI more streamlined and allow patients access to this form of diagnostic following head trauma.

In the image below, the varying colors represent the orientation of various white matter within the brain. In the second image, neurological specialists have the ability to zoom in on a specific location and can visualize a physical abnormality or disruption in neuronal activation due to a disturbance in neuronal integrity.

Images Obtained from Journal of Neuroradiology

So how do we lower the cost of imaging?

We start by locating private medical companies that offer this type of imaging. There were several speakers at the symposium who owned businesses that focused on the neurological diagnosis and treatment of individuals who suffered traumatic head injuries. The businesses offer consultations and diagnostics at a fraction of the cost of normal imagining techniques.

Cognitive and Behavioral Effects of Head Trauma 

Neuropsychologists want to make one thing very clear to all health practitioners: There is no such thing as the average TBI patient. While there are several concussion treatment protocols, it is paramount that each case be treated on an individual basis according to the needs of the patient and the underlying symptoms present. Cognitive changes following head trauma occur on a varying spectrum, and can include, but are not limited to: changes in vigilance, reaction time, mental tracking, verbal retrieval, mood and information processing.

Common symptoms that can be seen are the emergence of anxiety, depression, inability to focus and difficulty sleeping. Each symptom can lead to frustration, impatience and social disconnect. There is one congruity with all of these cognitive and behavioral changes: a concussion is a physiologic injury of the brain, where normal cerebral flow has been altered and the normal “algorithm” of information input and output has been compromised.

Unfortunately, head injuries cannot be cured; however, there is hope for individuals seeking refuge from this life-alerting injury. There are many clinics that exist, such as the UCF Psychology Clinic that can help patients learn to cope with the inhibiting effects of head trauma. Treatments include consultations with neuropsychologists, who walk patients through cognitive rehabilitative exercises and various forms of talk therapy. These treatments can help an individual compensate for the mental, emotional or physical deficiency that has arisen. The goal of treatment is to help the individual learn how to live within this new reality, and how to improve their overall quality of life.

The central message of the symposium is concussion research and concussion management are constantly changing. Unfortunately, policy change happens at an even slower rate. Due to this constant evolution, this is a topic All medical, fitness and cognitive specialists need to stay up to date on this topic due emerging information and the constant evolution of the topic. This can be accomplished by staying up to date on the latest research and emerging trends, in order to be able to follow “best practices” and avoid liability.


1. Hagmann, P., Jonasson, L., Maeder, P., Thiran, J. P., Wedeen, V. J., & Meuli, R. (2006). Understanding diffusion MR imaging techniques: from scalar diffusion-weighted imaging to diffusion tensor imaging and beyond 1. Radiographics, 26(suppl_1), S205-S223.

2. Le Bihan, D., Urayama, S. I., Aso, T., Hanakawa, T., & Fukuyama, H. (2006). Direct and fast detection of neuronal activation in the human brain with diffusion MRI. Proceedings of the National Academy of Sciences, 103(21), 8263-8268.

3. Rutgers, D. R., Toulgoat, F., Cazejust, J., Fillard, P., Lasjaunias, P., & Ducreux, D. (2008). White matter abnormalities in mild traumatic brain injury: a diffusion tensor imaging study. American Journal of Neuroradiology, 29(3), 514-519.

About the Author

Desi Rotenberg, originally from Denver, Colorado, graduated with his bachelor's degree in 2012 from the University of Northern Colorado. He has been a BOC Certified Athletic Trainer since 2012 and earned his master's degree in Exercise Physiology from the University of Central Florida in 2014. He currently is a high school teacher, teaching anatomy/physiology and leadership development. Along with being a teacher, he wears many hats, such as basketball coach, curriculum developer and mentor. He has been a contributor to the BOC Blog since the summer of 2015. 



NATM in New York City

Posted February 8, 2017

By Lauren Stephenson, MA, ATC

“Athletic Trainers Save Lives.”

“Every Body Needs an Athletic Trainer.”

“We’ve Got Your Back.”

“We Prepare You Perform.”

“A Safer Approach to Work, Life & Sport.”

“Your Protection is Our Priority.”

Every March Athletic Trainers (ATs) are dedicated to promoting National Athletic Training Month (NATM) and the athletic training profession. At Stony Brook University (SBU), we began a NATM tradition in 2012 with an inaugural trip to the “TODAY Show” in New York City to help kick-off NATM. The first year, there were a total of 30 students, faculty and staff attending all wearing university attire and carrying signs promoting the NATM slogans.  The trip was a huge success!  We received recognition from the hosts of the show and enjoyed some great group activities. The activities included breakfast at Ellen’s Stardust Diner on Broadway and a visit to the Body Worlds exhibit. The trip made such an impact that we decided to continue the tradition the following year.

In 2013, our group of now almost 50 including alumni (and we thought 2012 was huge), made the very early-morning, and much colder, trek into New York City for another amazing day. Our group filled an entire side of the “TODAY Show” corral with ATs and AT students. We followed this with breakfast at Ellen’s Stardust Diner s and a tour with Jim Ramsay, head AT for the New York Rangers at Madison Square Garden.

With a couple of years’ experience under our belt, we decided to make an even bigger impact in 2014 by inviting our colleagues from all of District 2. This was the biggest success yet with over 200 ATs and AT students lining the entire “TODAY Show” corral.  We held signs with our new NATA logo and were proud to represent all regions of District 2, now this was huge.  Our breakfast at Ellen’s Stardust Diner became a networking event for students from varying institutions. Then, the SBU crew followed that with a custom mouth guard workshop at New York City dental school.

In preparing for our 2015 event, we wanted to make our NATM kick-off tradition have an even greater impact Let’s get the word out that March is National Athletic Training Month! So we decided to not only attend the “TODAY Show”, but to also include the audience of “Good Morning America.” In addition, we invited District 1 to join us. In 2015, we gathered 100 ATs and students at each location and gained recognition from Robin Roberts at “Good Morning America.”  Our breakfast networking continued at Ellen’s Stardust Diner and several schools attended the Body World Exhibit together.

In 2016, we continued this tradition of attending 2 shows and set an all-time record of over 250 ATs and students! After breakfast, the SBU crew enjoyed an amazing experience with performing arts ATand SBU alumnus, Monica Lorenzo, MS, ATC at Radio City Music Hall. Lorenzo is an ATfor The Radio City Rockettes.

2017 marks our sixth year for NATM in New York City. It has become a tradition, not only for SBU, but for many ATs and AT programs in the northeast. We have over 13 institutions throughout Districts 1 and 2 represented and are looking forward to promoting this year’s slogan: “Your Protection is Our Priority.”

Every year we receive snap shots from people watching their TVs all over the US. They are always excited to see friends and colleagues and our NATA logo plastered across their morning news screens.  It has always been our goal to promote our profession. However, our event has evolved into an experience of camaraderie among all those in attendance, sharing an unparalleled experience of professional pride.

Being in New York City, we are lucky we have access to some of the largest morning news shows in the country. However, we recognize that travel to New York City in March is not feasible for ATs across the US. We have found this type of NATM event to be very rewarding, and we hope you join us in seeking out your local morning news show to help promote the athletic training profession in March. Here are some tips for making a successful local event:

1. Find out if your local news station allows visitors for a live audience.

2. If they allow visitors, check in with other local AT programs and ATs to see if they want to attend.

- Local AT associations also can send out a mass email with your contact info.

- The more people the greater the impact.

3. Make a spreadsheet that includes one contact for each interested institution.

4. When you a have general idea of how many will be in attendance, use the NATA PR Toolkit for NATM to create a press release and send it to the news station. You can find the NATA PR Toolkit at  https://www.nata.org/advocacy/public-relations/national-athletic-training-month.

5. Create an itinerary for the day and make sure you arrive very early to get a good spot.

- Be detailed so everyone knows where to go and who to direct questions from the producers to.

- Breakfast or a fun event afterward is always a bonus.

6. If you can’t get a large group together, just get started with your own group and it will grow from there.

If you’re interested in attending NATM in New York City or would like some guidance on starting your own event, please contact lauren.stephenson@stonybrook.edu. You can follow our event on Facebook at www.facebook.com/NATMinNYC  or on the “TODAY Show” or “Good Morning America” on March 3, 2017.

Happy National Athletic Training Month!




Exam Security: Protect Athletic Training Candidates and Yourself

Posted January 26, 2017

Sharing is usually a good thing, but this is not the case when preparing students for the BOC exam or discussing it with them after. It is illegal and unethical to memorize and discuss questions that are on the BOC exam, and both candidates and Program Directors are reminded to keep exam information confidential.

Prior to sitting for the BOC exam, candidates agree in the Candidate Attestation to not disclose information about items or answers in any format to anyone. This includes, but is not limited to:

- Educators

- Past or future examinees

- Co-workers

- Test preparation companies

The Candidate Attestation asserts that no part of the exam may be copied or reproduced in any way before, during and after exam. This includes, but is not limited to, emailing, copying or printing electronic files, reconstructing content through memorization and/or dictation.

BOC exam content is exclusive copyrighted property of the BOC and protected by federal copyright laws. The BOC will prosecute violations of this agreement. Violation of the agreement is also a violation of BOC Standards of Professional Practice, which can result in suspension or revocation of certification, if applicable, or suspension or denial of a candidate’s eligibility for future exams. It can also do the same for a candidate’s colleagues.

The below table presents common scenarios that could violate exam confidentiality. Read on for guidance in each scenario. More information is also available in the BOC Exam Candidate Handbook.

Scenario When it’s OK When it’s not OK Bottom line

1. Educator asks candidates to “stop by” after the exam to “let me know how it went.”

If the invitation and the feedback to the educator relates to their general experience (“I thought the test was not as difficult as I expected…”).

This type of invitation from an educator may be misinterpreted by the candidate – and the student may think that the educator is asking the student to reveal copyrighted information.

If the candidate is asked to reveal questions or their answer options, then he or she will need to report the educator to the BOC. The educator should stop the candidate immediately from revealing any exam content, since doing so may subject both the candidate and educator to the BOC’s ethics process.

2. Candidate tells another candidate, “The test was very difficult – I felt like I didn’t have enough time.”

The candidate is simply telling another candidate how they felt about the exam. This is all right because the candidate is not revealing any of the questions or the answer options.

One candidate (or potential candidate) asks another candidate about the specific questions.

If the questions or answer options are shared, these individuals may find themselves part of a BOC ethics investigation and/or legal complaint.

3. Candidate to educator: “You didn’t teach me about this question that asked [specific question]. I felt unprepared.”


It is not all right and it will never be all right to reveal the BOC’s copyrighted questions (or answer options) to anyone.

Candidates sign documentation stating that they will not share exam questions, and the BOC expects the candidates to abide by this contract. Those who don’t may find themselves part of a BOC ethics investigation and/or legal complaint.

4. A future candidate learns from a past candidate that, "Your BOC exam will have both multiple choice and the new multiple response kind of items. I think there were a little over 100 questions on each session.”

Candidates are welcome to discuss any information that is found on the BOC website, including the TYPES of items used on the various exams.

If the conversation goes beyond exam format and the past candidate begins to describe exam questions and answers to the future exam-taker, a breach of ethics has occurred.

As long as the conversation is limited to public information that anyone can read on the BOC website, such as exam format and style of item presentation, there is no problem. However, the past candidate should refrain from sharing specific exam content with the future candidate to protect not only the past exam-taker but also the future one.

5. A future candidate is in class when the professor announces, "Everyone pay attention to this example. It came from a BOC exam. It will show up on another exam someday soon." In another class, the professor insisted that, "This is ALWAYS guaranteed to be a BOC exam question. This is one concept that you don’t want to forget.”

There is no acceptable circumstance in which it is OK for an educator to offer to any class or audience any item or material directly linked to any BOC exam.

Since all BOC exam material including all items (questions and answers) is copyrighted, it is illegal for anyone to reproduce and use these items in any manner whatsoever. Candidate exposure to BOC exam items is legally and ethically limited to candidates' time spent taking BOC exams. Sample items available on the BOC website are not active items and may be shared.

All candidates should be aware that unsolicited classroom exposure to BOC exam material may result in cancellation of their own exam scores and/or may lead to being barred from taking the BOC exam in the future. It also should be remembered that new exam items constantly are being generated and can deal with any topic in the BOC practice analysis.

Sources: Scenarios 1-3 are from American Registry of Radiologic Technologists. Scenarios 4 and 5 are from National Board of Examiners in Optometry, Inc. Content has been adapted for the BOC.

Patient Reported Outcomes in Clinical Practice

Posted January 17, 2017

Beth Druvenga

By Beth Druvenga, M.S. Ed, LAT, ATC

As athletic training pushes to the forefront of healthcare professions, it is necessary for us to also change with the times. The Institute of Medicine urges healthcare educational programs to incorporate outcomes that are reported by the patient into their curriculum as to enhance clinicians’ decision making processes and drive forward patient centered care.1 Patient reported outcomes (PROs) are a valuable tool for Athletic Trainers (ATs) to add to their arsenal of evaluating their patient as a whole. With the addition of PROs into educational programs,1 this gives the student a chance to learn how and when to utilize these outcomes. It also makes it easier to analyze and interpret the results.

Many clinicians are hesitant to use PROs, especially in the fast-paced world of athletic training. Some of the greatest barriers to using PROs are time, comprehension and independence. Most clinicians and patients, report that it takes too much time to complete the surveys, and therefore, do not want to include them in their plan of care. Others report that patients don’t understand the questions and cannot properly fill out the survey without dependence on the clinician.1 How can we break through these barriers?

Initially, it may take time to walk the patient through the survey, but after they understand it, they can independently complete it at subsequent times. On the patient’s side, they can complete the survey while they are hooked up to electrical stimulation, icing or heating. This breaks down the time, comprehension and dependency barriers. It could be easily argued that recording PROs is as important to the patient’s rehab as recording objective measures of range of motion, strength and flexibility.

Once you’ve decided to use PROs, there are some things to consider for picking the correct outcome measure to use. First is to select the type of PRO. There are PROs to record the overall health related quality of life, the patient’s whole body health or information that focuses directly to one area of the body. The PRO that focused directly to one area of the body will be best suited for the outcomes most ATs will want to measure.

Once the type is determined, it’s time to decide on the quality of the PRO. In determining the quality, a clinician should look at the reliability and validity of the measure. This is to make sure that the outcome measure accurately shows change over time for the intended population and evaluates items which are important to the clinician and the patient. 2 Other elements to look at are the stability of the measure to reproduce a same score when a patient’s health status has not changed and responsiveness to detect how true the change in the score is over time.2

Along with the internal elements of the outcome measure, the measure also should be patient and clinician friendly, easy to use and score and support the goals that have been made for the patient. If you are interested in adding PROs into your practice but are still not sure where to go, http://www.orthopaedicscores.com/ is a valuable website. This resource has PROs grouped into specific categories as well as offers printable excel files.

One of the best reasons to use patient reported outcomes is to increase communication with the patient and to direct the patient’s care plan.1 Utilizing PROs in conjunction with clinician reported outcomes can enhance the rehabilitation process. Imagine the scenario of a patient returning from ACL surgery. By utilizing PROs, they will be able to see their progress from day 1 to present. As ATs, we watch our patients go through the highs and the lows of their rehabilitation process, including days where they feel like they haven’t made any progress. PROs, in conjunction with clinician reported outcomes, are valuable tools to utilize in helping patients reach their goals.


1. Snyder Valier, A. R., Jennings, A. L., Parsons, J. T., & Vela, L. I. (2014). Benefits of and Barriers to Using Patient-Rated Outcome Measures in Athletic Training. Journal of Athletic Training, 674-683.

2. Valier, A. R., & Lam, K. C. (2015). Beyond the Basics of Clinical Outcomes Assessment: Selecting Appropriate Patient-Reported Outcomes Instruments for Patient Care. Athletic Training Education Journal, 91-100.

About the Author

Beth Druvenga is an Athletic Trainer currently living in northern Virginia. She has experience working in both a collegiate and high school setting. Druvenga is originally from Iowa where she earned her Bachelor of Arts degree in Athletic Training from Central College in 2012. She graduated from Old Dominion University in 2014 with a Master of Science in Education. Her professional interests include patient-reported outcomes, psychology of injury and rehabilitation as well as using yoga to increase flexibility.