Sport-Related Concussion II: Managing the Injured Athlete and Return-to-Play Decision Making

Mary Alexis Iaccarino and Ross Zafonte

BACKGROUND

As defined by the International Conference of Concussion in Sport consensus statement, a concussion is a “complex pathophysiological process affecting the brain, induced by biomechanical forces” from a direct blow to the head or transferred force to the head from a blow to the body [1]. It results in a typical constellation of nonfocal symptoms and neurophysiological changes that are generally short lived and not associated with structural damage to the brain or abnormalities on conventional neuroimaging modalities [1]. The Centers for Disease Control and Prevention estimates an incidence rate of 1.8 to 3.6 million sports and recreational concussions per year or about 2 to 3 concussions per 10,000 player exposures (practice or game) [2,3]. This chapter will discuss assessment and management of the concussed athlete, with an emphasis on criteria and factors to consider when returning an athlete to the playing field.

Symptoms of Concussion

Observable and historical on-field or sideline signs of concussion are gait instability, a dazed or blank stare, brief confusion, slowed speech, slowed response to questions, brief anterograde amnesia, and retrograde amnesia. Traumatic loss of consciousness may occur as a part of concussion but it is not a defining clinical feature and is usually brief, only a few seconds [4].

Symptoms reported on the sidelines include headache, feeling mentally foggy or confused, dizziness, visual symptoms, and nausea. Common symptoms reported in the first 24 hours include headache, dizziness, imbalance, nausea, fatigue, blurred vision, sensitivity to light and noise, confusion, and memory impairment. Over several days, additional symptoms of sleep disturbance, irritability, anxiety, and nervousness may occur [5]. Cognitive symptoms, such as difficulties with attention and concentration, may become apparent in the days following a concussion, particularly when the athlete returns to academic or vocational activities.

MANAGEMENT OF CONCUSSION

Sideline Management

Athletes suspected of concussion are removed from play for assessment and should not be allowed to return-to-play on the same day. While it was once felt that same day return-to-play could be safe in some athletes, a more conservative approach has now been adopted. There is a subset of athletes in whom symptom recognition is delayed. The signs of concussion may not be obvious on initial sideline evaluation and may continue to evolve over time and with repeat assessment [6]. Furthermore, athletes are likely to underreport symptoms as they want to continue to play and may think their symptoms are mild enough that they can still play safely.

Signs that an athlete may have injuries more severe than concussion include focal neurological deficits, injury mechanism consistent with spine involvement (e.g., high velocity, fall from a height), suspected skull fracture (otorrhea, rhinorrhea, raccoon eyes, Battle’s sign), bleeding from the nose or ear, and/or seizure. Initial Glasgow Coma Scale (GCS) less than 13, GCS less than 15 after 2 hours, or declining GCS is concerning for serious intracranial pathology. Athletes with these findings should undergo head and cervical spine stabilization with immediate transfer to the emergency room [7].

Rest

After a concussion a period of rest is advised for athletes. The exact benefit of rest, the extent of restrictions, and duration that it should be prescribed is in question [8]. The rationale for rest after concussion is multifactorial. (a) The concussed brain is thought to be in a state of energy crisis and decreased neurometabolic demand may, theoretically, promote symptom recovery [9,10]. (b) Alterations in cerebral metabolism during concussion may be amplified with overlapping injuries [11,12]. (c) Exercise after neurotrauma has suppressed markers of neuroplasticity in animal models [13,14].

The meaning of “rest” is poorly defined, but generally includes reduced physical and cognitive activities. Cognitive rest such as staying home from school, reducing school work, limiting watching television or using electronics (computers, cell phones, games), limiting social visits, and avoiding loud noise and bright lights have unclear evidence. Thus, the prescription of rest should be directed toward limiting symptoms, while preventing social isolation and slowed progress in school. The optimal duration of rest is not known, with current recommendations based mostly on consensus and varying widely from several days to many weeks. While most athletes rest for 1 to 3 days before beginning some activity there is insufficient evidence to show that prolonged periods of rest improve outcomes [15]. Furthermore, prolonged rest should be prescribed with caution as restricting athletes can lead to physiological deconditioning, depression, anxiety related to falling behind in school or work, and rumination with potential symptom amplification [16].

Assessing Recovery

Clinical recovery is determined by improvement in symptoms, cognition, and balance. There are a variety of assessment instruments available to evaluate recovery, including the postconcussion symptoms scale (PCS), modified Balance Error Scoring System (mBESS), standard assessment of concussion (SAC), the King-Devick, ImPACT® test, and full neuropsychological testing, among others. These instruments have varying degrees of reliability and validity. The mBESS, SAC, and King-Devick test have rapidly diminishing sensitivity over the first 24–72 hours, meaning patients may appear clinically normal on these tests but still be recovering. Due to the variability in individual tests, the most sensitive method of assessing recovery is through testing batteries which incorporate symptom scales, physical exam findings, and cognitive performance tests [17].

Neurometabolic recovery does not necessarily correlate with clinical recovery, and diagnostic imaging studies or serological tests are lacking. There is concern that neurometabolic recovery may lag behind clinical recovery and this is part of the rationale for a conservative approach and graded return-to-play in the asymptomatic period after concussion [18].

Education and Anticipatory Guidance

Aside from rest, a mainstay intervention in the management of concussion is athlete education. Educational interventions vary and may include one-to-one discussion with the medical provider and/or athletic trainer, handouts and brochures, referral to reliable electronic references, or a formal educational lecture. Content of educational interventions should include common symptoms, likely time course of recovery, the importance of adherence to rest and return-to-play protocols, and reassurance that the overwhelming majority of athletes make a full recovery. Careful counseling regarding potential neurologic sequelae is needed to avoid elements of diagnosis threat via negative suggestion.

Return to Learning Following Concussion

Return to the classroom is a major concern for student athletes. Normal school activities such as studying, sitting in class, looking at computers/projectors, or eating lunch in a cafeteria can be very difficult following a concussion; these activities may even exacerbate postconcussion symptoms. Teachers, parents, and other adults may not be sensitive to the discomfort of the child and may not attribute declining school performance to concussion. Although a brief absence from school may be needed for severe symptoms, return-to-school does not require the athlete to be completely symptom-free. Cognitive challenges that do not exacerbate symptoms are acceptable. Physicians should take an active role in providing a return-to-learn plan. Specific instructions should be provided to the school so that the athlete may participate as tolerated in classroom activities with accommodations and breaks when needed [19,20]. It is suggested that health care professionals who regularly evaluate school-age concussed patients use an accommodation form such as the one presented in Table 10.1.

All student athletes should demonstrate successful return-to-learn before returning to sports. This means that the athlete attends full days of school, completes homework and assignments without increased time, and performs at preconcussion baseline on school exams and projects.

Return-to-Play Guidelines

Athletes must progress through a graduated return-to-play protocol, beginning with demonstration of an asymptomatic presentation while at rest, followed by a stepwise increase in physical exertion [1]. Each step should be separated by at least 24 hours. Any recurrence of postconcussion symptoms at a particular level of exertion requires the athlete to drop back to the previous level. For example, if an athlete is asymptomatic while riding a stationary bike (stage 2) but develops a headache with running drills (stage 3), then the athlete should return to biking (see Table 10.2).

For an athlete to return-to-play, he or she must complete the graded return-to-play protocol without symptoms and demonstrate baseline neuropsychological test performance, when such data is available. Furthermore, if the athlete were treated with any medication to ameliorate postconcussion symptoms, they must discontinue the medication and demonstrate that they are asymptomatic without medication prior to beginning the return-to-play protocol.

TABLE 10.1 Return to School Accommodations Form

Student _________________ Grade ___ School ____

This student has had a concussion and may experience symptoms such as impaired concentration and memory, headache, light and noise sensitivity, dizziness, and balance problems. Please allow for the following accommodations:

___ Extra time (Child may need additional time to complete assignments)

___ Please allow student to turn in assignments late

___ Please allow student extra time to complete quizzes and tests

___ Please allow student to take breaks if symptoms become worse

___ Please allow student to wear sunglasses while at school

___ Please allow student to wear ear plugs while at school

___ Please allow student/parent to meet with guidance counselor/teachers to develop a makeup/keep up plan for necessary assignments

___ Student should not be required to complete standardized testing until __________

___ This student should not be attending gym or should not be allowed to participate in physical activities during recess.

___ This student can tolerate low level physical activities such as walking

___ This student can participate in physical exertion but not in group physical activities

___ This student can participate fully in gym

TABLE 10.2 Return-to-Play Protocol

Initial Management Following Injury

When a player shows any symptoms or signs of a concussion, the following should be applied:

The player should not be allowed to return to play the same day as the concussion.

The player should not be left alone, and regular monitoring for deterioration is essential, over the initial few hours after injury.

The player should be medically evaluated after the injury.

Return-to-play must follow a medically supervised stepwise process.

A player should never return-to-play while symptomatic.

Return-to-Play Protocol

It is important to emphasize to the athlete that physical and cognitive rest is required.

The return to play after a concussion follows a stepwise process:

Stage 1: No activity, relative physical and cognitive rest

Stage 2: Light aerobic exercise such as walking or stationary cycling, no resistance training; Goal: Increase heart rate

Stage 3: Sport specific exercise, e.g., skating in hockey, running in soccer; Goal: Add movement

Stage 4: Noncontact training drills, e.g., passing drills, stick drills. Begin progressive resistance training; Goal: Physical and cognitive stress

Stage 5: Full contact practice, after medical clearance; Goal: Restore confidence and assess skills

Stage 6: Game play

With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current stage. If postconcussion symptoms recur, the patient should drop back to the previous asymptomatic stage for at least 24 hours and then try to progress again.

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