Rarely does a week pass without some mention in the lay media about sports-related concussions, sustained at the amateur or professional level of competition. Recently, the topic of head injuries in the National Football League (NFL) prompted a congressional hearing, fostering a widening discussion and debate about the actual incidence of concussion in the NFL, and the steps being taken to insure the safety of involved athletes.
The increased interest in sports-related concussion comes on the heels of the Third International Conference on Concussion in Sport, which was held during November 2008 in Zurich, Switzerland. A select group of expert attendees summarized their understanding of sports-related concussions, and their recommendations within a consensus statement. This statement is meant for wide distribution and use by physicians, physical/occupational therapists, certified athletic trainers, health professionals, coaches and others involved in the care of injured athletes (all ages; amateur through professional levels).
Here are the key points from the Zurich conference:
What is a Concussion?
This is a complex pathophysiological process that affects the brain, one that is induced by traumatic biomechanical forces. The most common features of a concussion are: (a) a direct blow to the head, face, neck, or elsewhere on the body. This direct blow creates in “impulsive” force that is transmitted to the head; (b) the blow results in a rapid onset of short-lived impairment in neurologic functioning, impairment that usually resolves spontaneously; (c) the blow may result in neuropathological changes with acute symptoms reflecting a disturbance in function (physical or cognitive performance), versus an actual structural injury to the brain; (d) the blow leads to a graded set of symptoms that may or may not involve an actual loss of consciousness; (e) there is a resolution of symptoms after a sequential course, with a small percentage of concussed individuals or athletes experiencing prolonged recovery, or post-concussive symptoms; and, (f) there is usually no abnormality detected on standard imaging studies of the brain of head (CT, MRI).
How is Concussion Classified and Managed Acutely?
The majority of all concussions (80 to 90%) resolve in a short period of time (approximately 7 to 10 days, post injury). This recovery time may be longer in children and adolescents. The usual signs and symptoms of concussion are headache, feeling dazed or in a fog, emotional lability (fluctuations in mood that are atypical for the individual), memory problems, slowed reaction time or processing speed, and sleep disturbance.
On-field or sideline evaluation approaches for acute concussion involve use of standard emergency management principles. These methods lead to a decision-making, regarding an athlete’s ability to continue play, and the need for additional assessment by other healthcare professionals, such as the team physician(s), or particular specialists. The severity of the concussion is often evaluated via sideline assessment tools, such as the SCAT2. Injured athletes are monitored serially over the first few hours post-concussion. Athletes should not return to play on the day of the injury. Usually, athletes are not returned to play until they are symptom free.
What is the Role of Neuropsychological Assessment?
Actual testing of an injured athlete’s thinking skills, using neuropsychological measures, has clinical value and merit. The results from this type of testing contribute to important evaluation information about the athlete’s post-concussion level of performance and functioning. Neuropsychological testing should be conducted when the adult athlete is symptom free; this testing may be introduced earlier in younger athletes that are still experiencing concussion-related symptoms. Often, decisions need to made about the younger athlete’s treatment needs and school-related adjustments. There may also be a need to track this younger athlete’s symptoms more closely using objective measures of cognition (neuropsychological testing).
What is Helpful About Concussion Management?
There is a need to follow an established return-to-play (RTP) protocol, after an athlete sustains a concussion. Usually, this involves no activity initially (complete cognitive and physical rest). Then, the athlete may be returned to light aerobic exercise. If no symptoms emerge, a sport-specific exercise is introduced. Non-contact training drills may come next, followed by full contact practice, and then actual RTP. The athlete’s progression through the RTP stages needs to be monitored closely. If the athlete exhibits an emergence of concussion-based symptoms, their progression through the stages is slowed: a return to an earlier stage is likely until there is no emergence of post-concussion symptoms.
Where available, a neuropsychologist should be involved in the RTP process. Baseline (pre-concussion) testing is recommended via computerized testing, such as ImPACT. Each player then serves as their own point of comparison, should they incur a concussion. Objectivity is enhanced with computer-based testing strategies, with proper supervision by a neuropsychologist. Further, use of computerized testing allows for the assessment of multiple athletes, increasing the efficiency of test administration, especially for large teams with busy training schedules. Post-injury testing can make use of multiple or alternative forms, which facilitates a cleaner assessment of concussion-based symptoms using measures that are less affected by an athlete’s familiarity with particular test items. The sensitivity of post-concussion, neuropsychological testing via computers can be enhanced with additional paper-and-pencil measures.
What About More Complex Cases?
When athletes experience the more atypical, prolonged recovery pattern post-injury, there will be a need to take a detailed history, one that searches for other, contributing factors. These other factors may include early developmental or learning problems, psychological or emotional factors, motivational issues, or non-concussion health conditions, such as chronic pain, sleep disturbance, medication side effects, use of non-prescribed drugs or alcohol, engagement in non-recommended physical or cognitive exercises, and other stressors in the athlete’s life.
Recommendations:
The Zurich conference and current concussion management strategies point to the importance of a thoughtful concussion management program, one that is multidisciplinary in approach. A good starting point for any concussion management program is a review of the current literature in this field, especially the recent consensus statements on sports-related concussion. Additionally, there is a need to insure that the multidisciplinary team involved in RTP decision-making is, in fact, working in a coordinated manner with a common body of knowledge. The ideal concussion management program includes a healthy dose of education for the athletes, the staff, and other interested parties.
One must keep in mind that the field of concussion management is evolving. There is no set standard of practice. There are known aspects of effective concussion management, however, and the implementation of these aspects can only be helpful to the involved athletes.
Dr. David Lechuga directs a small neurobehavioral clinic in Lake Forest, California. His practice specializes in assessing and treating individuals with brain injuries. Dr. Lechuga is adjunct clinical faculty at UCLA and Pepperdine University. He is the neuropsychologist for the Los Angeles Kings Hockey Club. Dr. Lechuga is a board member for Next Season.
