Abstract
Introduction
While delayed removal from play has been associated with worse outcomes following sport-related concussions (SRC), factors that predict delayed removal (vs. immediate) remain poorly understood. This study aimed to identify predictors of delayed removal following an SRC.
Methods
A retrospective analysis included athletes aged 12–23 who presented to a regional sports concussion center within one day of injury. Patient demographics, injury characteristics, and clinical recovery metrics were extracted from medical records. Removal timeline was categorized as immediate (removed from play at time of injury) or delayed (continued participation). Comparisons across groups and a multivariable logistic regression model were conducted to identify predictors of delayed removal.
Results
In 291 athletes (29.6% female, median age = 15.6 [IQR = 14.5–16.8]), 109 (37.5%) had delayed removal (29.4% female; median age 15.7 [IQR 14.5–16.9]). Sex, race, sport, school, and competition type did not differ significantly between immediate and delayed removal groups. Athletes with loss of consciousness (LOC) had over 81% lower odds of delayed removal (OR = 0.19, 95%CI: 0.08–0.44; p < 0.01), and those evaluated on the field had 70% lower odds of delayed removal (OR = 0.30, 95%CI: 0.17–0.54; p < 0.01). Initial symptom scores were lower among those immediately removed (19.0 [IQR = 6.0–38.2]) compared to the delayed removal group (24.0 [IQR = 11.0–44.0]; p = 0.05). Return-to-learn, symptom resolution, and return-to-play timelines did not differ significantly between groups.
Conclusion
On-field evaluations and observable clinical signs such as LOC strongly reduced risk of delayed removal from play after SRC. These findings emphasize the critical role of athletic trainers and prompt sideline recognition in reducing delayed removal and acute symptom burden.
Keywords: Brain Concussion, Sports, Sport-Related Concussion
1. Introduction
Sport-related concussions (SRC) affect millions of athletes across all ages and levels of play [1,2]. Despite increased public awareness and management guidelines, it is estimated that over 50% of SRCs go unreported in the United States [3]. Many athletes delay symptom disclosure or choose not to disclose their symptoms due to fear of losing playing time or negatively affecting the team's overall success [4]. Especially in sports with high rates of SRC, athletes may also fear letting their coaches or teammates down due to team culture expectations that often prioritize team success over the well-being of individual athletes [2,4,5]. This underreporting may delay recognition of concussion and removal from play, which are crucial components of concussion management.
Delayed removal from play may have several negative consequences. In a meta-analysis of both high school and collegiate athletes, those who delayed symptom reporting took an average of 5 additional days to return to play compared to those who disclose their symptoms immediately [6]. Furthermore, in a study of 69 pediatric athletes (aged 12–19), delayed removal from play was associated with greater symptom severity post injury at both post-injury days 1–7 and 8–30, as well as a longer recovery time (44 days vs 22 days) [7]. In a more specific analysis of removal timeline, Asken et al. demonstrated that collegiate athletes with a delayed removal from competition were more than twice as likely to have a prolonged clearance for return to contact activity (i.e., 8 or more days) [8]. In follow up work, the authors found that those with a delayed removal often presented with more severe symptom burdens during the first 48 h post-injury and took approximately 3 additional days to fully return to sport participation [9]. Other work suggests a dose–response relationship between continued play and recovery, with athletes who continued to participate for ≤15 min or >15 min after injury demonstrating progressively longer recovery times and higher odds of protracted recovery compared with those removed immediately [10].
Although prior studies have established a relationship between removal timeline and recovery outcomes, less is known about the factors (e.g., sport, competition setting, or other injury characteristics) that predict whether an athlete is removed immediately following a concussion-causing injury or continues to play for any or all of their sporting event. Recognizing removal as a modifiable risk factor aligns with recent recommendations from the Concussion in Sport Group Consensus Statement, which emphasizes removal from play when concussion is suspected to reduce risk of further injury [1]. By identifying contextual predictors of delayed removal, providers (such as on-field certified athletic trainers; ATCs) may be better equipped to intervene and optimize athlete safety.
This study sought to characterize removal timelines (immediate vs delayed removal) among athletes with SRC and to identify key predictors of delayed removal from play. We hypothesized that on-field evaluation and observable signs would be associated with lower odds of delayed removal, and that factors such as school type (private vs. public), high-contact sports (e.g. football), and competition environment (game vs. practice) might influence removal timing.
2. Methods
2.1. Study design and statement of ethics
This retrospective cohort study was approved by the institutional review board (No. 222278) and deemed exempt without consent required.
2.2. Patient selection criteria
Patients evaluated for SRC at a regional sports concussion center between 11/2017-04/2022 were eligible. Inclusion criteria included those who presented to a regional sports concussion center acutely post-injury and were subsequently diagnosed with an SRC. Patients were initially identified via ICD-9 and ICD-10 codes (850.∗ and S06.0X∗∗) or post-concussion syndrome (310.2 and F07.81) and manually reviewed by trained individuals. Inclusion criteria were patients who: (1) were between the ages of 12-23-years-old at the time of their injury, (2) were diagnosed with a concussion by a clinic provider, and (3) were seen by a provider at a regional sports concussion clinic within 1 day of injury. This decision was two-fold in that we wanted to fully capture acute symptom severity while also ensuring patient symptoms had not started to resolve. Previous research has indicated that symptom severity may decrease hourly after injury [11], with some symptoms being most pronounced within the first 24 h of injury [12]. Additionally, information from the patient's electronic medical record (EMR) must have been sufficient to identify removal timeline.
2.3. Data collection and independent variables
Data was manually extracted from each patient's EMR and included demographics (e.g., age, sex, race, school type, sport), medical history (e.g., prior number of concussions) and injury characteristics. Injury characteristics included experiencing loss of consciousness (LOC), experiencing amnesia, and receiving an evaluation on-field by athletic trainer (yes/no). The ‘History of Present Illness’ portion of the patient's clinic note was reviewed to determine if the concussion-causing event occurred during a game or practice, as well as when the patient was removed from play. Removal from play was dichotomized into two groups (1) immediate removal from play [i.e., player was removed immediately following the concussion causing event and did not return to play]: and (2) delayed removal from play [i.e., the patient was not immediately removed following the concussion causing event or continued playing for at least several plays following the event]. Initial Post-Concussion Symptom Scale (PCSS) severity score [13,14] was also extracted. The PCSS is a 22-item self-reported measure that assesses symptom severity on a 7-point Likert scale and was administered and collected at the first clinic visit. All data were securely managed in a REDCap electronic database.
2.4. Outcome variables
The primary outcome was immediate or delayed removal. Secondary outcome variables were days to return-to-learn (RTL), symptom resolution (SR), and return to play (RTP). Days to RTL was defined as when a patient returned to any amount of school. Days to SR was defined as a patient reporting a 0 on a self-reported PCSS or a return to their baseline PCSS score. Days to RTP was defined as when the patient completed the return to play protocol. Any of these outcomes that were noted to be greater than 90 days had the value truncated to exactly 90 days to keep outliers from overly influencing statistical models.
2.5. Statistical analysis
Descriptive statistics characterized the sample including demographic information, personal and family medical history, injury characteristics, and recovery metrics. Several variables were dichotomized, including race (white vs. non-white) and sport (football vs. not football). Non-football sports included soccer, basketball, rowing/crew, baseball, softball, cheerleading, volleyball, ice hockey, rugby, lacrosse, horseback riding, flag football, boxing, gymnastics, and mountain biking. Continuous variables (e.g., age, initial PCSS, recovery metrics) were reported as medians with interquartile range (IQR). The immediate removal from play and delayed removal from play groups were compared using Mann–Whitney U tests because Shapiro–Wilk tests examining the outcome variables suggested non-normal distributions (all p-values < 0.05). Categorical variables (e.g. sex, race, prior concussion, school type, amnesia, loss of consciousness (LOC), on-field evaluation, competition type, sport) were reported as frequencies, and group analyses were completed using Chi–Square tests. A multivariable logistic regression was established for predicting delayed removal (coded as 1; immediate removal coded as 0 in regression). Other variables in the model included age, sex (reference: male), race (reference: white), prior concussion history (treated as a binary variable with reference: no prior concussion), loss of consciousness (reference: none), and on-field evaluation (reference: none). Patients with incomplete information were excluded from the regression (i.e. case-complete analysis), and cases coded as ‘Unsure’ or ‘Unknown’ were excluded from statistical comparisons or regressions. An additional exploratory, qualitative analysis was performed to identify potential reasons for delayed removal among athletes who were also evaluated by an ATC. Statistical significance was set a priori at p ≤ 0.05, and all analyses were performed using Python version 3.13.
3. Results
3.1. Demographics
Of the 2086 patients in our regional database, 1132 fit the study age range with an SRC. Patients who presented to the clinic more than one day after injury were excluded (n = 679). Of the remaining 453 patients, a total of 291 met inclusion criteria with adequate data on removal timing (182 (62.5%) immediate, 109 (37.5%) delayed). The groups were predominately male (70.3% vs. 70.6%, respectively) and white (64.8% vs. 70.6%). This was the first concussion for most patients (67.0% vs. 64.2%). The majority of athletes attended public school (50.5% and 57.8%, respectively). None of these factors differed significantly between the immediate and delayed removal groups on Chi–Square analyses (all p-values > 0.05, Table 1).
Table 1.
Demographic, injury, and recovery characteristics between immediate and delayed removal
| Overall (n = 291) | Immediate (n = 182) | Delayed (n = 109) | Statistics | ||
|---|---|---|---|---|---|
| Age, median (IQR) | 15.6 (14.5–16.8) | 15.5 (14.5–16.8) | 15.7 (14.5–16.9) | U: 10172.0 | p = 0.72 |
| Sex (n (%)) | χ2: 0.0 | p = 1.00 | |||
| Male | 205 (70.4%) | 128 (70.3%) | 77 (70.6%) | ||
| Female | 86 (29.6%) | 54 (29.8%) | 32 (29.4%) | ||
| Race (n (%)) | χ2: 0.8 | p = 0.37 | |||
| White | 195 (67.0%) | 118 (64.8%) | 77 (70.6%) | ||
| Non-white | 96 (33.0%) | 64 (35.2%) | 32 (29.4%) | ||
| Prior concussion (n (%)) | 99 (34.0%) | 60 (33.0%) | 39 (35.8%) | χ2: 0.1 | p = 0.72 |
| School type (n (%)) | χ2: 0.1 | p = 0.76 | |||
| Public | 155 (53.3%) | 92 (50.5%) | 63 (57.8%) | ||
| Private | 54 (18.6%) | 34 (18.7%) | 20 (18.3%) | ||
| Not listed/Unknown | 82 (28.2%) | 56 (30.8%) | 26 (23.9%) | ||
| Amnesia (n (%)) | 81 (27.8%) | 56 (30.8%) | 25 (22.9%) | χ2: 1.8 | p = 0.18 |
| LOC (n (%)) | 68 (23.4%) | 60 (33.0%) | 8 (7.3%) | χ2: 23.8 | p < 0.01 |
| On-field evaluation (n (%)) | χ2: 15.8 | p < 0.01 | |||
| Yes | 149 (51.2%) | 108 (59.3%) | 41 (37.6%) | ||
| No | 95 (32.6%) | 44 (24.2%) | 51 (46.8%) | ||
| Unsure | 47 (16.2%) | 30 (16.5%) | 17 (15.6%) | ||
| Competition type | χ2: 0.1 | p = 0.72 | |||
| Game | 126 (43.3%) | 69 (37.9%) | 57 (52.3%) | ||
| Practice | 63 (21.6%) | 32 (17.6%) | 31 (28.4%) | ||
| Other/Unknown | 102 (35.1%) | 81 (44.5%) | 21 (19.3%) | ||
| Sport | χ2: 0.1 | p = 0.76 | |||
| Football | 116 (39.9%) | 71 (39.0%) | 45 (41.3%) | ||
| Not football | 175 (60.1%) | 111 (61.0%) | 64 (58.7%) | ||
| Initial PCSS, median (IQR) | 21.0 (8.0–41.0) | 19.0 (6.0–38.2) | 24.0 (11.0–44.0) | U: 9225.5 | p = 0.05 |
| Time to RTL, median (IQR) | 4.0 (2.0–8.0) | 4.0 (2.0–7.8) | 4.0 (2.0–9.2) | U: 7752.0 | p = 0.52 |
| Time to SR, median (IQR) | 15.0 (7.0–35.2) | 15.0 (6.0–43.0) | 15.0 (8.0–28.5) | U: 4918.5 | p = 0.96 |
| Time to RTP, median (IQR) | 18.0 (12.0–36.2) | 18.0 (11.0–44.0) | 18.5 (12.8–30.0) | U: 4806.5 | p = 0.71 |
IQR = Interquartile Range. LOC = Loss of consciousness. PCSS = Post-Concussion Symptom Scale. RTL = Return to Learn. SR = Symptom Resolution. RTP = Return to Play. Not Football sports included: soccer, basketball, rowing/crew, baseball, softball, cheerleading, volleyball, ice hockey, rugby, lacrosse, horseback riding, flag football, boxing, gymnastics, and mountain biking.
∗Chi-square tests only included cases with known values, unlisted values or values denoted as ‘unknown’ were excluded.
3.2. Injury and competition details
The competition type was similar between groups (p = 0.72). Within the immediate removal group, 37.9% were injured during a game, 17.6% during practice, and 44.5% were unable to be classified. In the delayed removal group, 52.3% were injured during a game, 28.4% during practice, and 19.3% were unable to be classified. There was a significant difference in the proportion of athletes who experienced LOC in the immediate removal group (33.0%) compared to the delayed group (7.3%) (p < 0.01). Additionally, the immediate removal group (59.3%) had a higher proportion of athletes receiving an on-field ATC evaluation compared to the delayed group (37.6%) (p < 0.01). There were no significant differences in the proportion of athletes who experienced amnesia or played football between the immediate and delayed groups (p > 0.05, Table 1).
3.3. Initial presentation and recovery metrics
Initial PCSS scores were significantly higher in the delayed removal group (24.0 [11.0–44.0]) compared to the immediate removal group (19.0 [6.0–38.2]) (p = 0.05, Fig. 1). The recovery timelines (i.e., time to RTL, time to SR, time to RTP) were similar between immediate and delayed removal groups (p > 0.05, Table 1).
Fig. 1.
Box Plot Comparing Initial Post-Concussion Symptom Scale severity score, stratified by group.
Note: PCSS = Post-Concussion Symptom Scale; IQR = Interquartile Range.
3.4. Predictors of delayed removal
The overall multivariable regression model predicting delayed removal was significant [χ2 (6) = 38.489, p < 0.01]. The model explained 19.9% (Nagelkerke R2) of the variance and correctly classified 70.4% of cases (Table 2, Fig. 2). Demographic factors (age, sex, race, or prior concussion history) were not independent predictors of delayed removal (all p-values > 0.05). Athletes who received an on-field ATC evaluation had 70% lower odds of delayed removal (OR 0.30, 95% CI 0.17–0.54, p < 0.01). Athletes who experienced loss of consciousness had 81% lower odds of delayed removal (OR 0.19, 95% CI 0.08–0.44, p < 0.01).
Table 2.
Logistic regression to predict delayed removal
| Overall Model Performance | |||||
|---|---|---|---|---|---|
| χ2 (6) = 38.489, p < 0.01 |
Nagelkerke R2: 0.199 |
Model Accuracy: 0.704 |
|||
| Variable Metrics | |||||
| OR | 95% CI | B | SE | p | |
| Age | 1.07 | 0.91–1.25 | 0.066 | 0.079 | 0.40 |
| Sex (Ref: Male) | 0.67 | 0.36–1.28 | −0.395 | 0.327 | 0.23 |
| Race (Ref: White) | 0.75 | 0.41–1.38 | −0.291 | 0.313 | 0.35 |
| Prior concussion (Ref: None) | 0.96 | 0.52–1.77 | −0.041 | 0.312 | 0.89 |
| On-field evaluation (Ref: None) | 0.30 | 0.17–0.54 | −1.213 | 0.300 | < 0.01 |
| Loss of consciousness (Ref: None) | 0.19 | 0.08–0.44 | −1.656 | 0.426 | < 0.01 |
Fig. 2.
Forest Plot of Odds Ratio and 95% Confidence Intervals from Multivariable Regression Assessing Factors for Delayed Removal from Competition, with Shading indicating Significant Predictors.
3.5. Clinical vignettes
A qualitative exploration of each patient's chart elucidated different patterns related to initial injury factors that may have contributed to delayed removal from play. For some patients, delayed removal was in part driven by an athlete delaying to report symptoms. In many cases, this was due to either a delayed onset of symptoms or the worsening of initial symptoms. Unfortunately, electronic record information was not detailed enough to delineate distinct classifications for many of these qualitative observations. Representative quotes are available for those with immediate removal and delayed removal in Table 3.
Table 3.
Select vignettes
| Pertinent History of Presenting Illness (de-identified) | |
|---|---|
| Immediate removal from play | “[Patient] sustained her first lifetime concussion in a soccer game … She reports being hit in the left temporal area of her head with a kicked ball at a distance of about 10 feet. Initial symptoms included dizziness, feeling [dazed], and headache. There was no loss of consciousness or amnesia. She was taken out of play by the game official. She was seen in the same day by her primary care physician and referred here.” |
| “[Patient] was playing the safety position and while going for the ball collided with another teammate. He reports brief loss of consciousness but no retrograde amnesia. Anterograde amnesia is estimated at about an hour. He was transported to a local hospital where CT scans of the head and neck were said to be normal. His father reports that his son was disoriented, cognitively slow, and did not know his date of birth at the time of the injury.” | |
| Delayed removal from play | “[Patient] reports an injury to the head during football. Head to head hit during tackling drill. No immediate symptoms. [They] started to feel very tired 10–15 min later. No LOC, no neck pain, [but endorsed] retrograde amnesia. As [they] walked into locker room after practice, [that] is when symptoms started and included [headache], nausea, dizziness, weakness, vision problems.” |
| “[Patient] sustained a concussion during a soccer game when she was hit in the back of her head with an elbow. No LOC or PTA but states she saw stars. She played for the remainder of the game. After game, mom described her as pale and she vomited. She was evaluated in the ED …” | |
| “… a very pleasant [patient] who reports an injury to the head during soccer. Slid to get to ball and hit back of head on ground. No LOC, no neck pain, no amnesia. Initial symptoms included [headache], dizziness, phonophobia, photophobia, confusion, weakness, numbness/paranesthesia, vision problems … Continued to play for 20 min and got worse. Told coach who removed from game and then was seen by home team ATC on the sideline. Mom took her to [ED] upon arrival back home due to continued symptoms” | |
| “[Patient] reports that he was returning a kickoff and received hit. He continued to play. There was no loss of consciousness or retrograde amnesia but he describes some spotty anterograde amnesia. During half-time he became dizzy … and irritable. He was seen by a certified athletic trainer and diagnosed with a concussion.” |
CT = Computed Tomography; LOC = Loss of Consciousness; PTA = Post-traumatic Amnesia; ED = Emergency Department; ATC = Certified Athletic Trainers.
4. Discussion
4.1. Summary of findings
This retrospective cohort study of athletes with a SRC examined differences in symptom severity and recovery timeline in those who had immediate versus delayed removal from play, along with factors predicting delayed removal. Athletes who had delayed removal from play were less likely to experience a loss of consciousness (LOC) or have on-field evaluation by an ATC. Demographic factors, sport type, and competition setting were not associated with removal timing. Both loss of consciousness and on-field evaluation by an ATC independently predicted lower odds of delayed removal from play. Those with a delayed removal from play had a significantly higher initial symptom burden; however, recovery timelines were similar for these athletes regardless of an immediate or delayed removal.
4.2. Context with prior literature
In our sample, athletes who had delayed removal from play had a higher initial symptom burden compared to those with immediate removal, consistent with prior studies. For example, Elbin et al. also found that those who removed from play immediately had significantly less reported symptoms than those who remained in play [7]. For athletes with delayed removal, the continued exertion may have contributed to symptom exacerbation. However, while our study found no difference in recovery timeline between these groups, Elbin et al. found that immediate removal was associated with shorter symptom duration [7]. Similarly, Asken et al. also found recovery duration was shorter in patients with an immediate removal [8]. Several factors may explain this discrepancy in recovery findings. Our cohort was restricted to athletes who presented within 1 day of injury to best capture immediate symptom burden, while Elbin et al. included patients who sought care later. Since our cohort began structured clinical management earlier, regardless of removal timeline, it is possible this helped mitigate previously observed delays in symptom resolution and recovery. While prior literature has explored delayed clinical evaluation (2–3 weeks after injury compared to within the first week) [15], future work may explore how more acute delays to clinical care within the first few days of injury influences recovery.
Notably, prior concussion history was not an independent predictor of delayed removal in our multivariable model. Evidence on the clinical impact of concussion history in athletes is mixed [16], though prior concussion history has been associated with greater acute symptom burden and longer recovery after a subsequent concussion [[17], [18], [19]]. Further, prior concussion experience does not necessarily translate into improved disclosure behaviors; greater concussion history has been associated with less favorable disclosure attitudes and lower self-reported disclosure in high school athletes, and disclosure decisions are influenced by multi-level social/contextual factors [5,20]. Taken together, this supports the interpretation that real-time sideline recognition and evaluation may be more influential than injury history alone in determining removal timing, which is consistent with our findings for LOC and on-field ATC evaluation.
Both LOC and on-field evaluation by an ATC were significant predictors for lower odds of delayed removal in our cohort. These findings align with consensus guidelines for SRCs, which recommend removal based on even suspected injury [1]. LOC is a conspicuous sign of injury, which often prompts more rapid recognition by teammates, coaches, referees, and medical personnel. Likewise, prior literature has shown that high availability of ATCs is associated with higher reporting for SRC [21]. Given that an ATC's primary focus at sporting events is player health, they are well positioned to detect both obvious and more nuanced signs of concussion that warrant removal and further evaluation.
4.3. Clinical implications
The presence of an ATC at a sporting event represents an important, modifiable system-level factor. In addition to prior literature showing that ATC availability is linked to increased concussion recognition [21], our findings specifically tie on-field ATC evaluation to immediate removal from play. This removal subsequently was associated with lower acute symptom burden at clinic presentation. From a public health and policy perspective, expanding ATC coverage for school and community-based athletics, especially in under-resourced settings, may be a pragmatic strategy to improve early SRC care. However, on-field evaluation alone may not be sufficient when symptoms are delayed, evolving, or not disclosed by the athlete. Prior research has found that many athletes may not disclose symptoms for fear of letting their team down or not wanting to leave the competition [4]. In our sample, clinical documentation among athletes who received on-field ATC evaluation but still had delayed removal most commonly suggested delayed symptom disclosure, or delayed onset or progression of symptoms after initial assessment. Though our observations should be viewed cautiously due to the small, qualitative nature of analysis, they highlight opportunities for ATCs and other first-line healthcare professionals to modify assessment protocols and decision-making. For instance, engaging in standardized re-assessments after high-risk injury mechanisms and incorporating messaging to normalize early symptom reporting may be helpful. These findings suggest that—in addition to broader ATC coverage—culture-level interventions to normalize early reporting may improve SRC outcomes. Future community efforts may focus on both increasing ATC presence at sporting events and counseling adolescent athletes, families, and coaches on the importance of symptom reporting and destigmatizing early play removal.
4.4. Limitations
This was a retrospective analysis from a single specialty sports concussion clinic, which can limit generalizability to all athletes and introduce selection bias. Instead of standardized metrics, outcomes were based on self-reported symptom scales and clinically documented milestones. Information regarding removal timing and on-field evaluation were extracted from clinical documentation, which contributed to missing data and limited context surrounding removal decisions. For example, for around one third of athletes, the competition setting was not readily extractable or clearly noted from clinical documentation. Further, because this was a retrospective clinic-based cohort, event-level medical coverage (e.g., whether an ATC was present at each game or practice) was not consistently documented in the EMR; therefore, lack of documented ATC evaluation may reflect absence of ATC coverage, lack of sideline evaluation despite available coverage, or incomplete clinical documentation. Additionally, PCSS scores were extracted from the first clinic visit rather than from a standardized sideline symptom checklist. Although all included athletes presented within one day of injury, this introduces potential variability between symptom onset, removal from play, and symptom severity measurement. Beyond LOC/amnesia, other observable signs (e.g. balance disturbance, convulsive features) were inconsistently documented, and the PCSS largely captures subjective symptoms rather than observable signs, limiting analyses comparing overt versus covert presentations between groups. Future work may focus on larger, multicenter studies with standardized sideline data collection to confirm these findings and better define factors that lead to more rapid removal from play following an SRC.
4.5. Conclusion
In this retrospective study, observable signs such as LOC and on-field ATC evaluation were associated with lower odds of delayed removal from play after SRC. Athletes with delayed removal from play had a higher initial symptom burden, though their recovery timeline was similar to those with immediate removal. These results emphasize the importance of sideline recognition, robust ATC coverage, and rapid clinical response to reduce symptom burden and promote safer concussion management.
Declaration of generative AI and AI-assisted technologies in the manuscript preparation process
During the preparation of this work the authors used OpenAI's ChatGPT to help edit sentence grammar and structure statistical analysis. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
Funding
None.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests.
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Douglas Terry, Ph.D., serves as a consultant/Senior Director of Research for the National Football League (NFL) and a scientific advisor for HitIQ. He previously consulted for REACT Neuro, Inc. He has a consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including former athletes). He receives grant funding from Amgen, Inc. and Football Research, Inc.
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Scott Zuckerman, MD, MPH, is a member of the NFL Head, Neck, and Spine Committee and a consultant for Medtronic.
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No other authors have any declarations or conflicts of interest to report.
Acknowledgements
None.
Footnotes
This article is part of a special issue entitled: Concussion prevention and surveillance published in JSAMS Plus.
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