Returning to play post-concussion: Ready or Not?
It's that time of year. The temperature is dropping, the leaves are changing color, and young men's/women's brains are getting knocked around inside their skulls. (Well that took a graphic turn...) I'm being literal and not holding back because this is a serious issue.
The gif demonstrates the coup-countercoup mechanism of what is medically categorized as mild Traumatic Brain Injury (mTBI), otherwise known as concussion.
Fall and winter are the time of collision sports. With college football and NFL seasons officially underway (and the NHL right around the corner), concussion will once again be a hot topic of discussion, and contention.
Before I go any further, let me say that I am not not anti-football (or hockey or any other sport). As a spectator, I actually love the game. It's 60 minutes of faced paced action, and every down has top play potential.
What I am is anti-recklessness. Participating in collision sports will always carry an inherent risk, but that doesn't mean we can't be smart about managing an athlete post-injury to better protect their long term safety and wellbeing. As a healthcare professional, I see gaps in the management of concussions, particularly in youth athletes. One retrospective study of elementary-collegiate athletes indicated 43.5% of concussed athletes returned to their sport too soon1.
I understand that athletics and sport come with certain pressures: from coaches, parents, or even self inflicted. I was a high school athlete that hid several injuries. And I hope by writing this it keeps other from making the same mistake, because in cases of concussion, premature return to play can have significant consequences for long term neurological health. What drives me nuts is that many of these situations should be preventable.
It is estimated that between 1.6 and 3.8 million concussions occur in the US annually2, with up to 50% going unreported3. Identification has reached unprecedented levels in recent years, thanks to ongoing pressure by the media and public alike.
After a concussion is identified, and once an athlete can resume physical activity, they are sent to physical therapy for rehabilitation of deficits and a return to play protocol. In terms of strategy, this involves a fairly straight forward process with certain milestones that need to be met before proceeding to the next stage.
What is often not straight forward, is the final milestone: returning to play. When is an athlete ready to return?
This should be a very easy question to answer, but is far too often a judgement call instead of a definitive yes/no.
If an athlete returns before their brain is completely recovered, a secondary blow to the head (even a minor one) can result in long term dysfunction3.
Again, this should be preventable, but many youth athletes are missing a vital piece of information when they are approaching a return to their sport.
Having a baseline of cognitive function and turns a subjective judgement (essentially asking the player if they feel "normal"), into an objective and unbiased decision.
A baseline examination can take up to half an hour and entails the following:
Completion of the Sports Concussion Assessment Tool or SCAT
Neurological Examination by a trained healthcare professional
Cranial Nerve Function
When considering returning to full activity, the same procedures are performed to assess for deficits. If the athlete doesn't meet their pre-concussion cognitive performance, they are not ready to return as they are still at greater risk for post-concussive exacerbation. Keep in mind this could take days, weeks, or even months!
If you or your child participate in a collision sport, or have a history of concussion, I urge you to get a baseline examination. It is a vital piece of information that can make return to sport as safe as possible.
If you want to get checked out and are in the north suburbs of Chicago, my colleagues an I at Team Sapiens Physical Therapy perform these examinations. For anyone else, if you don't know where to get started, reach out! We will work with you to find a provider in your area.
1 - Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: Physician’s chart review. Canadian Family Physician. 2014;60(6):e310-e315.
2 - Abrahams S, Fie SM, Patricios J, et alRisk factors for sports concussion: an evidence-based systematic reviewBr J Sports Med 2014;48:91-97.
3 - Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clinical Journal of Sport Medicine. 2013;23:1-18.