- Email: [email protected]
Sports Concussion in an Adolescent
Point/Counterpoint
Sports Concussion in an Adolescent
Guest Discussants: Jeffrey T. Barth, PhD, ABPP-CN
CASE SCENARIO A 16-year-old high school football player who is a highly recruited scholar athlete presents after an apparent sports concussion. He is an “A” student and has no ongoing substance abuse or family issues. He has no significant medical history except an ulnar fracture at age 7 when he fell from a bicycle. No loss of consciousness was noted, and no posttraumatic amnesia was reported after his bicycle accident. Early in the season, the patient experienced a “rung bell” and altered sensorium for 1–2 minutes during a game. He had no other symptoms. He returned to play after 1 week but developed symptoms upon exertion. In a subsequent practice session within a week after his return to play, he also suffered a “minor blow,” followed by confusion for 1 minute. Before beginning the current season, the subject underwent baseline neuropsychological testing, as ordered by his coach. Upon further questioning, the patient revealed that he had developed intermittent frontal headaches, exacerbated by exertion, in addition to experiencing malaise and fatigue. He also noted sleep disturbance and altered performance in school (with grades that declined rapidly and recovered to baseline). At this juncture, it is 4 weeks after the second event, and the patient has been asymptomatic upon exertion for 2 weeks. What are your return-to-play (RTP) recommendations?
Brain Injury and Sports Concussion Institute, University of Virginia School of Medicine, Charlottesville, VA Disclosure: nothing to disclose
Cara Camiolo-Reddy, MD Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA Disclosure: nothing to disclose
Senior Editor: Ross Zafonte, DO Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital and Harvard University, Boston, MA; e-mail: [email protected] Disclosure: nothing to disclose
Jeffrey Barth, PhD, ABPP-CN, Responds RTP decision-making can be complex, and in the case of multiple concussions within a week of each other as well as the age of the patient, the most prudent approach is to be conservative and consensus driven. The medical team (often made up of a physician, athletic trainer, and neuropsychologist) should apply appropriate RTP algorithms, which are based upon many years of sports concussion research, consensus statements [1,2], and the experience of leaders in the field of sports medicine. When either the Cantu [3-5] or the American Academy of Neurology [6] severity and concussion management guidelines are applied, one can conclude that this 16-yearold high school student sustained 2 grade 1 concussions based upon “1 to 2 minutes of altered sensorium” and “confusion for 1 minute” at the time of injury. The subsequent development of “intermittent headaches exacerbated by exertion, malaise, and fatigue,” as well as “sleep disturbance and altered performance in school” that “recovered to baseline” after the second concussion, is concerning. However, because the patient has been symptom PM&R 1934-1482/09/$36.00 Printed in U.S.A.
free upon exertion for 2 weeks, and his academic performance has returned to baseline, most criteria would be met for RTP. Because members of the patient’s high school sports program had the foresight to initiate baseline neuropsychological assessment, a decision to RTP should also be contingent on equal or better performance on postconcussion testing (with exertion) when compared with baseline scores. Because of the possibility of second impact syndrome (SIS) in this age group, this high school football player should be given information about the symptoms of concussion, as should the rest of the team, and it should be stressed that he must immediately report any postconcussion symptoms he experiences subsequent to his RTP and practice [7]. Educating families about concussions also can be helpful in identifying and safely managing these injuries. This player should be monitored closely, and his participation in contact sports and practice should be terminated for the season if he experiences a third concussion. © 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 769-773, August 2009 DOI: 10.1016/j.pmrj.2009.07.001
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REFERENCES 1. McCory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: The 3rd international conference on concussion in sport held in Zurich, November 2008. PM&R 2009;1:406420. 2. Aubry M, Cantu R, Dvorak J, et al. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11.
POINT/COUNTERPOINT
3. Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Phys Sports Med 1986;14:75-83. 4. Cantu RC. Head injuries in sport. Br J Sports Med 1996;30:289-296. 5. Cantu RC. An overview of concussion consensus statements since 2000. Neurosurgery 2001;Focus 21:E3. 6. American Academy of Neurology. Practice parameter: The management of concussion in sports (summary statement). Neurology 1997;48:581-585. 7. Cantu RC. Second-impact syndrome. Clin Sports Med 1998;17:37-44.
Cara Camiolo-Reddy, MD, Responds Returning athletes to play after a sports-related head injury can be a difficult decision for physicians. The decision must be individualized and made via an evidence-based approach. I have abandoned the use of concussion grading scales in favor of individualized assessment and management. To make my decision on this athlete’s RTP, I would suggest further medical evaluation, neuropsychological testing, and possibly, neuroimaging. This individualized approach should include both medical evaluation and neuropsychological assessment. For this athlete, medical evaluation at 4 weeks after trauma should include a comprehensive history and physical examination. A thorough review of symptoms includes investigation of sleep changes, headaches, nausea, dizziness, mood or personality changes, and cognitive symptoms including perceived “fogginess,” difficulty concentrating, memory impairments, and feeling slowed down. An educational history also should be taken because a rapid decline in grades or productivity after injury may indicate cognitive symptoms. Physical examination with comprehensive neurologic and balance assessment should be routine. For acute management of head trauma, computed tomography is invaluable to rule out more serious injury; however, athletes with unresolving symptoms should undergo more sensitive neuroimaging, such as magnetic resonance imaging, to rule out any underlying pathology or markers of more severe injury, including diffuse axonal injury. It should be noted that neuroimaging is typically normal, even with grossly symptomatic athletes. Given a normal physical examination and neuroimaging, neuropsychological testing has been found to uniquely contribute to the assessment of the athlete by providing sensitive, reliable, and valid measure of subtle deficits of concussive injury. In a population that minimizes symptoms for secondary gain, this testing can provide objective data to aid in education and decision-making. For example, van Kampen
et al [1] found statistically significant cognitive deficits with neuropsychological testing of athletes reporting themselves as being asymptomatic. As recognized by the International Conference on Concussion in Sport, baseline neuropsychological data and repeated postinjury testing is considered to be a cornerstone of proper concussion management [1,2]. Proper management of this athlete would include repeat postinjury neurocognitive testing to investigate any neurocognitive deficits associated with the concussion. Postinjury results should reveal a return to preinjury baseline scores as a marker of recovery. For athletes with a preinjury baseline, postinjury scores can be compared to normative values to estimate recovery. Current standards for RTP require that the athlete (1) is asymptomatic at rest, (2) is asymptomatic upon exertion (both physical and cognitive), and (3) has neuropsychological testing return to baseline. When the athlete meets these criteria, it is thought that he or she can safely return to sport; however, the athlete’s personal medical and concussion history, neuroimaging findings, and age should also be taken into consideration. Although no standards currently exist for these factors, the potential risks of returning to contact sports must be addressed with any athlete who has sustained multiple concussions, who has had prolonged recovery from a concussion, or who has had positive posttrauma neuroimaging [3].
REFERENCES 1. Van Kampen D, Lovell MR, Collins MW, et al. The “value added” of neurocognitive testing in managing sports concussion. Am J Sports Med 2006;34:1630-1635. 2. Aubry M, Cantu R, Dvorak J, et al. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11. 3. McCrory P, Johnston K, Meeuwisse W, et al. Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med 2005;15:48-55.
Editor’s Follow-up Questions: Should the Age of the Athlete Make a Difference in the Timing of RTP (ie, a 16- Versus 22-Year-Old Athlete)? Dr. Barth Responds The age of the athlete is considered an important factor in RTP decisions on the basis of concerns over potential SIS and animal research indicating neurologic vulnerability in the developing
brain. SIS is a catastrophic neurological outcome after 2 mild concussions in close temporal proximity and under circumstances in which recovery from the first concussion is incomplete. Almost all recorded cases of SIS have involved athletes younger than the age of 21 [1]. Hovda et al’s research [2] on
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glucose utilization and physiological cascades after concussions (by the use of fluid percussion models) in mice has demonstrated much longer recovery times for immature mice than mature ones, thus longer vulnerability to second injury. On the basis of these studies, I tend to be more cautious with younger athletes (which I would define as middle school and high school), giving them more time to fully recover. It should be noted that the brain is still developing to about age 25; thus, college athletes can also fall into this category of greater risk/ vulnerability.
REFERENCES 1. Cantu RC. Second-impact syndrome. Clin Sports Med 1998;17:37-44. 2. Hovda DA, Prins M, Becker DP, Lee S, Bergsneider M, Martin NA. Neurobiology of concussion. In: Bailes JE, Lovell MR, Maroon JC. Sports Related Concussion. St. Louis, MO: Quality Medical Publishing; 1999, 12-51.
Dr. Camiolo-Reddy Responds Adolescent athletes have been found to have longer periods of recovery compared with older athletes. Field et al [1] compared recovery rates in collegiate and high school athletes and found that high school athletes took longer to recover their neurocog-
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nitive deficits when compared with older athletes, data that were corroborated in a study [2] in which the authors compared professional and high school football players. This finding echoes pathophysiologic evidence that the pediatric brain is 60 times more sensitive to the effects of glutamate, an excitatory amino acid that is thought to play a role in the neurometabolic cascade of concussion as detailed by Giza and Hovda [3]. It has been suggested that these age-related physiologic differences, including prolonged and diffuse cerebral swelling, may increase the risk of secondary injury and SIS. As a result, immature brains may be more vulnerable to the effects of a second insult, underscoring the need for a more conservative clinical approach for adolescent athletes.
REFERENCES 1. Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 2003;142:546-553. 2. Pellman EJ, Lovell MR, Viano DC, Casson IR. Concussion in professional football: Recovery of NFL and high school athletes assessed by computerized neuropsychological testing—part 12. Neurosurgery 2006:58:263-274. 3. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train 2001;36:228-235.
What is the Risk of Sustaining Further Concussions on the Basis of Historical Data? Dr. Barth Responds The rule of thumb is that each successive concussion reduces the threshold for sustaining another concussion and that recovery times will increase after each repeat concussion. Controlled research in this area is limited. However, case studies and professional experience with athletes experiencing multiple concussions suggests a strong relationship between number and severity of concussions and vulnerability to sustaining future concussions and related symptoms. Repeat concussions can occur with less severe impact and acceleration.
Dr. Camiolo-Reddy Responds The cumulative effects of repeated brain trauma have been well-documented in boxers and soccer players. Mounting
clinical evidence in high school and collegiate athletes suggests that those who sustain 3 or more concussions are at risk for longer recovery times, have more severe on-field presentation after subsequent injuries, and may be more vulnerable for future injury [1,2]. Once again, this evidence highlights the need for an individualized approach that takes into account all aspects of the athlete’s medical and concussive history, as well as proper education of athletes, parents, and coaches on the potential risks of return to sport.
REFERENCES 1. Collins MW, Lovell MR, Iverson GL, et al. Cumulative effects of concussion in high school athletes. Neurosurgery 2002;51:1175-1181. 2. Fazio V, Lovell M, Pardini J, Collins M. The relation between post concussion symptoms and neurocognitive performance in concussed athletes. Neurorehabilitation 2007;22:207-216.
Because The Second Concussion Was Precipitated by a More Minor Event, How Should That Factor Influence Level of Concern for Further Risk and Timing of RTP Decisions? Dr. Barth Responds Symptoms after a second, more minor event is concerning and suggests more risk for a longer recovery and sustaining a third concussion. In addition, as stated previously, the brain will likely be more vulnerable to the effects of future head trauma and perhaps more serious neurologic and neurocognitive sequelae. Every case is individual, but I would err on the conservative side to be sure that the athlete is not experiencing neurologic symptoms (upon exertion) and is able to
perform at or above the baseline (preseason) level of neurocognitive functioning, before allowing RTP.
Dr. Camiolo-Reddy Responds The notion that a more minor event precipitated the second concussion brings us back to the concept that the immature brain may have a prolonged period of vulnerability, lowering the threshold for sustaining another injury. Clinicians treating adolescents should take extra care
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in evaluating these athletes by using comprehensive history and examination findings in conjunction with neuro-
POINT/COUNTERPOINT
psychological testing to assure the patient has met all criteria for RTP.
What Is the Role of Neuropsychological Testing in Determining RTP and Future Risk? Dr. Barth Responds Brief baseline neurocognitive assessment is a wonderful safety net in difficult and complicated RTP decision-making. If an athlete sustains a concussion and is symptomatic (with or without exertion), he should not return to play or practice. Neuropsychological testing is not necessary in such a clearly symptomatic case. However, if the concussed player is asymptomatic with exertion but there are concerns about whether he has returned to his preconcussion state, comparing baseline to current neurocognitive testing can be a vital part of the decision-making process. They can also be useful when the medical team wishes to be cautious, such as cases with the pediatric population, with multiple concussion history, or when it unclear if the athlete has accurately reported symptoms. Although there is value in using paper-and-pencil neurocognitive tests, most sports programs today use brief computerized test procedures that have been proven to be useful with sports concussions. In our studies of mild head injury, the use of Sports as a Laboratory Assessment Model (ie, SLAM) and baseline neurocognitive assessments are helpful for each player because of the great variability in athletes’ neurocognitive abilities and the often subtle effects of concussion [1-3]. Comparing a player’s postconcussion performance to baseline adequately addresses these issues and provides sensitive adjunctive data to the history and physical exam.
2. Macciocchi SN, Barth JT, Alves WM, Rimel RE, Jane JA. Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery 1996;39:510-514. 3. Barth JT, Freeman JR, Broshek DK, et al. Acceleration-deceleration sportsrelated head injury: The gravity of it all. J Athl Train 2001;36:253-256.
Dr. Camiolo-Reddy Responds Computerized neuropsychological testing has been one of the most significant advances in the field of sports concussion, offering both sensitive and specific objective data for postinjury cognitive functioning. The clinical utility of neuropsychological testing has been validated by multiple studies [1,2]. Van Kampen et al [1] reported that neuropsychological testing was 20% more sensitive than symptom reporting alone for identifying injury. They further found statistically significant cognitive deficits in athletes reporting themselves as being asymptomatic [1]. The computerized modality also provides an ease of administration, allowing many athletes to be tested during the preseason. After injury, athletes can be serially reassessed to assure they have returned to their baseline values. On the basis of these data, the International Conference on Concussion in Sport has recommended that neuropsychological testing should be the “cornerstone” for injury assessment and return-to-play decision making [2].
REFERENCES REFERENCES 1. Barth JT, Alves WM, Ryan T, et al. Mild head injury in sports: Neuropsychological sequelae and recovery of function. In: Levin HS, Eisenberg HM, Benton AL, eds. Mild Head Injury. New York: Oxford Press; 1989, 257-275.
1. Van Kampen D, Lovell MR, Collins MW, et al. The “value added” of neurocognitive testing in managing sports concussion. Am J Sports Med 2006;34:1630-1635. 2. Aubry M, Cantu R, Dvorak J, et al. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11.
What Would You Advise if This Were Your Child? Dr. Barth Responds I would allow him to return to play if he was symptom free with exertion and his neurocognitive test performance (also with exertion) was better than baseline levels. I would carefully observe his play and monitor his symptoms to be sure that he doesn’t suffer another concussion. Further, I would impress upon him and his coaches, athletic trainers, and team physician that sustaining another concussion should be avoided. However, if he were to experience another concussion with symptoms, he should stop play (and practice) immediately and report this to the medical team. In my opinion, any young person experiencing a third concussion should terminate play (and practice) for the rest of the season. Actually, I would likely tell him to end his contact
sports career for good (particularly after deliberating with my wife and concerned mother).
Dr. Camiolo-Reddy Responds I would proceed cautiously, given his age, the significant symptoms reported, and the succession of injuries. With neuropsychological testing scores at baseline, I would allow him to return to contact sports if he was performing academically at his usual level and participating in sport-specific noncontact drills without any symptom exacerbation. His coaching staff and teachers would need clear instruction and education so that they could alert us of any change in performance or if a new injury was suspected. As the mother of a toddler, I can only hope my son will view football as a spectator sport only!
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Ross Zafonte, DO, Senior Editor Commentary The role of the physiatrist in returning individuals to play carries substantial clinical implications. During the past decade, several criteria for the grading and treatment of concussion have been developed. These criteria are based on consensus statements and clinical examination findings; however, all lack physiologic correlates. Even the forces required to produce a concussion remain a controversy [1]. The implications of premature return can be devastating, and no clinician is ever completely sure an individual has been transparent in reporting all symptoms [2]. It is rather comforting to know that our 2 experts have taken a relatively similar approach to return of this young athlete. However, they do have somewhat-different approaches to the problem, with one having a greater focus on the guidelines and the other on clinical symptoms. In almost every case, critical clinical factors such as age, the previous number of concussions, sports career status, and timing of the season supplement the decision paradigm. Except for strongly compelling “special cases,” the recently published Zurich sports concussion consensus statement [3] includes the guidelines that at least present a reasonable path to follow. Neuropsychological testing before and after the incident remains a virtual gold standard, and few supplemental tests exist as clinically available tools. Perhaps in this case, balance testing electrophysiology might have yielded some additional information [4]. Further discussion is underway to evaluate physical markers such as soft neurological signs as an adjunct to neurocognitive testing. However, concerns
exist regarding the role of multiple exposures to concussion and long-term physiologic changes that occur as measured by magnetic stimulation [5]. Additional long-term concerns include the role of multiple minor traumas in the development of posttraumatic encephalopathy. Although no proven adjunct biologic testing yet exists, the movement toward physiologic metrics is necessary to further quantify risk and evaluate improvement. Even when such diagnostic tools are more readily available, they are unlikely to completely eliminate the emotional and clinical concerns involved in returning a successful athlete with multiple concussive exposures to play.
REFERENCES 1. Hamberger A, Viano D, Saljo A, Boloruri H. Concussion in professional football: Morphology of brain injuries in the NFL concussion model. Neurosurgery 2009;64:1174-1182. 2. Byard R, Vink R. The second impact syndrome. Forensic Sci Med Pathol 2009;5:36-38. 3. McCory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: The 3rd international conference on concussion in sport held in Zurich, November 2008. PM&R 2009;1:406-420. 4. Davis G, Iverson G, Guskiewcz K, Ptito A, Johnston K. Contributions of neuroimaging, balance testing electrophysiology and blood markers to the assessment of sports-related concussion. Br J Sports Med 2009;43: i36-i45. 5. DeBeaumont L, Theoret H, Mongeon D, et al. Brain function decline in healthy retired athletes who sustain their last sports concussion in early adulthood. Brain 2009;132:695-708.
Sports Concussion in an Adolescent
Guest Discussants: Jeffrey T. Barth, PhD, ABPP-CN
CASE SCENARIO A 16-year-old high school football player who is a highly recruited scholar athlete presents after an apparent sports concussion. He is an “A” student and has no ongoing substance abuse or family issues. He has no significant medical history except an ulnar fracture at age 7 when he fell from a bicycle. No loss of consciousness was noted, and no posttraumatic amnesia was reported after his bicycle accident. Early in the season, the patient experienced a “rung bell” and altered sensorium for 1–2 minutes during a game. He had no other symptoms. He returned to play after 1 week but developed symptoms upon exertion. In a subsequent practice session within a week after his return to play, he also suffered a “minor blow,” followed by confusion for 1 minute. Before beginning the current season, the subject underwent baseline neuropsychological testing, as ordered by his coach. Upon further questioning, the patient revealed that he had developed intermittent frontal headaches, exacerbated by exertion, in addition to experiencing malaise and fatigue. He also noted sleep disturbance and altered performance in school (with grades that declined rapidly and recovered to baseline). At this juncture, it is 4 weeks after the second event, and the patient has been asymptomatic upon exertion for 2 weeks. What are your return-to-play (RTP) recommendations?
Brain Injury and Sports Concussion Institute, University of Virginia School of Medicine, Charlottesville, VA Disclosure: nothing to disclose
Cara Camiolo-Reddy, MD Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA Disclosure: nothing to disclose
Senior Editor: Ross Zafonte, DO Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital and Harvard University, Boston, MA; e-mail: [email protected] Disclosure: nothing to disclose
Jeffrey Barth, PhD, ABPP-CN, Responds RTP decision-making can be complex, and in the case of multiple concussions within a week of each other as well as the age of the patient, the most prudent approach is to be conservative and consensus driven. The medical team (often made up of a physician, athletic trainer, and neuropsychologist) should apply appropriate RTP algorithms, which are based upon many years of sports concussion research, consensus statements [1,2], and the experience of leaders in the field of sports medicine. When either the Cantu [3-5] or the American Academy of Neurology [6] severity and concussion management guidelines are applied, one can conclude that this 16-yearold high school student sustained 2 grade 1 concussions based upon “1 to 2 minutes of altered sensorium” and “confusion for 1 minute” at the time of injury. The subsequent development of “intermittent headaches exacerbated by exertion, malaise, and fatigue,” as well as “sleep disturbance and altered performance in school” that “recovered to baseline” after the second concussion, is concerning. However, because the patient has been symptom PM&R 1934-1482/09/$36.00 Printed in U.S.A.
free upon exertion for 2 weeks, and his academic performance has returned to baseline, most criteria would be met for RTP. Because members of the patient’s high school sports program had the foresight to initiate baseline neuropsychological assessment, a decision to RTP should also be contingent on equal or better performance on postconcussion testing (with exertion) when compared with baseline scores. Because of the possibility of second impact syndrome (SIS) in this age group, this high school football player should be given information about the symptoms of concussion, as should the rest of the team, and it should be stressed that he must immediately report any postconcussion symptoms he experiences subsequent to his RTP and practice [7]. Educating families about concussions also can be helpful in identifying and safely managing these injuries. This player should be monitored closely, and his participation in contact sports and practice should be terminated for the season if he experiences a third concussion. © 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 769-773, August 2009 DOI: 10.1016/j.pmrj.2009.07.001
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REFERENCES 1. McCory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: The 3rd international conference on concussion in sport held in Zurich, November 2008. PM&R 2009;1:406420. 2. Aubry M, Cantu R, Dvorak J, et al. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11.
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3. Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Phys Sports Med 1986;14:75-83. 4. Cantu RC. Head injuries in sport. Br J Sports Med 1996;30:289-296. 5. Cantu RC. An overview of concussion consensus statements since 2000. Neurosurgery 2001;Focus 21:E3. 6. American Academy of Neurology. Practice parameter: The management of concussion in sports (summary statement). Neurology 1997;48:581-585. 7. Cantu RC. Second-impact syndrome. Clin Sports Med 1998;17:37-44.
Cara Camiolo-Reddy, MD, Responds Returning athletes to play after a sports-related head injury can be a difficult decision for physicians. The decision must be individualized and made via an evidence-based approach. I have abandoned the use of concussion grading scales in favor of individualized assessment and management. To make my decision on this athlete’s RTP, I would suggest further medical evaluation, neuropsychological testing, and possibly, neuroimaging. This individualized approach should include both medical evaluation and neuropsychological assessment. For this athlete, medical evaluation at 4 weeks after trauma should include a comprehensive history and physical examination. A thorough review of symptoms includes investigation of sleep changes, headaches, nausea, dizziness, mood or personality changes, and cognitive symptoms including perceived “fogginess,” difficulty concentrating, memory impairments, and feeling slowed down. An educational history also should be taken because a rapid decline in grades or productivity after injury may indicate cognitive symptoms. Physical examination with comprehensive neurologic and balance assessment should be routine. For acute management of head trauma, computed tomography is invaluable to rule out more serious injury; however, athletes with unresolving symptoms should undergo more sensitive neuroimaging, such as magnetic resonance imaging, to rule out any underlying pathology or markers of more severe injury, including diffuse axonal injury. It should be noted that neuroimaging is typically normal, even with grossly symptomatic athletes. Given a normal physical examination and neuroimaging, neuropsychological testing has been found to uniquely contribute to the assessment of the athlete by providing sensitive, reliable, and valid measure of subtle deficits of concussive injury. In a population that minimizes symptoms for secondary gain, this testing can provide objective data to aid in education and decision-making. For example, van Kampen
et al [1] found statistically significant cognitive deficits with neuropsychological testing of athletes reporting themselves as being asymptomatic. As recognized by the International Conference on Concussion in Sport, baseline neuropsychological data and repeated postinjury testing is considered to be a cornerstone of proper concussion management [1,2]. Proper management of this athlete would include repeat postinjury neurocognitive testing to investigate any neurocognitive deficits associated with the concussion. Postinjury results should reveal a return to preinjury baseline scores as a marker of recovery. For athletes with a preinjury baseline, postinjury scores can be compared to normative values to estimate recovery. Current standards for RTP require that the athlete (1) is asymptomatic at rest, (2) is asymptomatic upon exertion (both physical and cognitive), and (3) has neuropsychological testing return to baseline. When the athlete meets these criteria, it is thought that he or she can safely return to sport; however, the athlete’s personal medical and concussion history, neuroimaging findings, and age should also be taken into consideration. Although no standards currently exist for these factors, the potential risks of returning to contact sports must be addressed with any athlete who has sustained multiple concussions, who has had prolonged recovery from a concussion, or who has had positive posttrauma neuroimaging [3].
REFERENCES 1. Van Kampen D, Lovell MR, Collins MW, et al. The “value added” of neurocognitive testing in managing sports concussion. Am J Sports Med 2006;34:1630-1635. 2. Aubry M, Cantu R, Dvorak J, et al. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11. 3. McCrory P, Johnston K, Meeuwisse W, et al. Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med 2005;15:48-55.
Editor’s Follow-up Questions: Should the Age of the Athlete Make a Difference in the Timing of RTP (ie, a 16- Versus 22-Year-Old Athlete)? Dr. Barth Responds The age of the athlete is considered an important factor in RTP decisions on the basis of concerns over potential SIS and animal research indicating neurologic vulnerability in the developing
brain. SIS is a catastrophic neurological outcome after 2 mild concussions in close temporal proximity and under circumstances in which recovery from the first concussion is incomplete. Almost all recorded cases of SIS have involved athletes younger than the age of 21 [1]. Hovda et al’s research [2] on
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glucose utilization and physiological cascades after concussions (by the use of fluid percussion models) in mice has demonstrated much longer recovery times for immature mice than mature ones, thus longer vulnerability to second injury. On the basis of these studies, I tend to be more cautious with younger athletes (which I would define as middle school and high school), giving them more time to fully recover. It should be noted that the brain is still developing to about age 25; thus, college athletes can also fall into this category of greater risk/ vulnerability.
REFERENCES 1. Cantu RC. Second-impact syndrome. Clin Sports Med 1998;17:37-44. 2. Hovda DA, Prins M, Becker DP, Lee S, Bergsneider M, Martin NA. Neurobiology of concussion. In: Bailes JE, Lovell MR, Maroon JC. Sports Related Concussion. St. Louis, MO: Quality Medical Publishing; 1999, 12-51.
Dr. Camiolo-Reddy Responds Adolescent athletes have been found to have longer periods of recovery compared with older athletes. Field et al [1] compared recovery rates in collegiate and high school athletes and found that high school athletes took longer to recover their neurocog-
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nitive deficits when compared with older athletes, data that were corroborated in a study [2] in which the authors compared professional and high school football players. This finding echoes pathophysiologic evidence that the pediatric brain is 60 times more sensitive to the effects of glutamate, an excitatory amino acid that is thought to play a role in the neurometabolic cascade of concussion as detailed by Giza and Hovda [3]. It has been suggested that these age-related physiologic differences, including prolonged and diffuse cerebral swelling, may increase the risk of secondary injury and SIS. As a result, immature brains may be more vulnerable to the effects of a second insult, underscoring the need for a more conservative clinical approach for adolescent athletes.
REFERENCES 1. Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 2003;142:546-553. 2. Pellman EJ, Lovell MR, Viano DC, Casson IR. Concussion in professional football: Recovery of NFL and high school athletes assessed by computerized neuropsychological testing—part 12. Neurosurgery 2006:58:263-274. 3. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train 2001;36:228-235.
What is the Risk of Sustaining Further Concussions on the Basis of Historical Data? Dr. Barth Responds The rule of thumb is that each successive concussion reduces the threshold for sustaining another concussion and that recovery times will increase after each repeat concussion. Controlled research in this area is limited. However, case studies and professional experience with athletes experiencing multiple concussions suggests a strong relationship between number and severity of concussions and vulnerability to sustaining future concussions and related symptoms. Repeat concussions can occur with less severe impact and acceleration.
Dr. Camiolo-Reddy Responds The cumulative effects of repeated brain trauma have been well-documented in boxers and soccer players. Mounting
clinical evidence in high school and collegiate athletes suggests that those who sustain 3 or more concussions are at risk for longer recovery times, have more severe on-field presentation after subsequent injuries, and may be more vulnerable for future injury [1,2]. Once again, this evidence highlights the need for an individualized approach that takes into account all aspects of the athlete’s medical and concussive history, as well as proper education of athletes, parents, and coaches on the potential risks of return to sport.
REFERENCES 1. Collins MW, Lovell MR, Iverson GL, et al. Cumulative effects of concussion in high school athletes. Neurosurgery 2002;51:1175-1181. 2. Fazio V, Lovell M, Pardini J, Collins M. The relation between post concussion symptoms and neurocognitive performance in concussed athletes. Neurorehabilitation 2007;22:207-216.
Because The Second Concussion Was Precipitated by a More Minor Event, How Should That Factor Influence Level of Concern for Further Risk and Timing of RTP Decisions? Dr. Barth Responds Symptoms after a second, more minor event is concerning and suggests more risk for a longer recovery and sustaining a third concussion. In addition, as stated previously, the brain will likely be more vulnerable to the effects of future head trauma and perhaps more serious neurologic and neurocognitive sequelae. Every case is individual, but I would err on the conservative side to be sure that the athlete is not experiencing neurologic symptoms (upon exertion) and is able to
perform at or above the baseline (preseason) level of neurocognitive functioning, before allowing RTP.
Dr. Camiolo-Reddy Responds The notion that a more minor event precipitated the second concussion brings us back to the concept that the immature brain may have a prolonged period of vulnerability, lowering the threshold for sustaining another injury. Clinicians treating adolescents should take extra care
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in evaluating these athletes by using comprehensive history and examination findings in conjunction with neuro-
POINT/COUNTERPOINT
psychological testing to assure the patient has met all criteria for RTP.
What Is the Role of Neuropsychological Testing in Determining RTP and Future Risk? Dr. Barth Responds Brief baseline neurocognitive assessment is a wonderful safety net in difficult and complicated RTP decision-making. If an athlete sustains a concussion and is symptomatic (with or without exertion), he should not return to play or practice. Neuropsychological testing is not necessary in such a clearly symptomatic case. However, if the concussed player is asymptomatic with exertion but there are concerns about whether he has returned to his preconcussion state, comparing baseline to current neurocognitive testing can be a vital part of the decision-making process. They can also be useful when the medical team wishes to be cautious, such as cases with the pediatric population, with multiple concussion history, or when it unclear if the athlete has accurately reported symptoms. Although there is value in using paper-and-pencil neurocognitive tests, most sports programs today use brief computerized test procedures that have been proven to be useful with sports concussions. In our studies of mild head injury, the use of Sports as a Laboratory Assessment Model (ie, SLAM) and baseline neurocognitive assessments are helpful for each player because of the great variability in athletes’ neurocognitive abilities and the often subtle effects of concussion [1-3]. Comparing a player’s postconcussion performance to baseline adequately addresses these issues and provides sensitive adjunctive data to the history and physical exam.
2. Macciocchi SN, Barth JT, Alves WM, Rimel RE, Jane JA. Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery 1996;39:510-514. 3. Barth JT, Freeman JR, Broshek DK, et al. Acceleration-deceleration sportsrelated head injury: The gravity of it all. J Athl Train 2001;36:253-256.
Dr. Camiolo-Reddy Responds Computerized neuropsychological testing has been one of the most significant advances in the field of sports concussion, offering both sensitive and specific objective data for postinjury cognitive functioning. The clinical utility of neuropsychological testing has been validated by multiple studies [1,2]. Van Kampen et al [1] reported that neuropsychological testing was 20% more sensitive than symptom reporting alone for identifying injury. They further found statistically significant cognitive deficits in athletes reporting themselves as being asymptomatic [1]. The computerized modality also provides an ease of administration, allowing many athletes to be tested during the preseason. After injury, athletes can be serially reassessed to assure they have returned to their baseline values. On the basis of these data, the International Conference on Concussion in Sport has recommended that neuropsychological testing should be the “cornerstone” for injury assessment and return-to-play decision making [2].
REFERENCES REFERENCES 1. Barth JT, Alves WM, Ryan T, et al. Mild head injury in sports: Neuropsychological sequelae and recovery of function. In: Levin HS, Eisenberg HM, Benton AL, eds. Mild Head Injury. New York: Oxford Press; 1989, 257-275.
1. Van Kampen D, Lovell MR, Collins MW, et al. The “value added” of neurocognitive testing in managing sports concussion. Am J Sports Med 2006;34:1630-1635. 2. Aubry M, Cantu R, Dvorak J, et al. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11.
What Would You Advise if This Were Your Child? Dr. Barth Responds I would allow him to return to play if he was symptom free with exertion and his neurocognitive test performance (also with exertion) was better than baseline levels. I would carefully observe his play and monitor his symptoms to be sure that he doesn’t suffer another concussion. Further, I would impress upon him and his coaches, athletic trainers, and team physician that sustaining another concussion should be avoided. However, if he were to experience another concussion with symptoms, he should stop play (and practice) immediately and report this to the medical team. In my opinion, any young person experiencing a third concussion should terminate play (and practice) for the rest of the season. Actually, I would likely tell him to end his contact
sports career for good (particularly after deliberating with my wife and concerned mother).
Dr. Camiolo-Reddy Responds I would proceed cautiously, given his age, the significant symptoms reported, and the succession of injuries. With neuropsychological testing scores at baseline, I would allow him to return to contact sports if he was performing academically at his usual level and participating in sport-specific noncontact drills without any symptom exacerbation. His coaching staff and teachers would need clear instruction and education so that they could alert us of any change in performance or if a new injury was suspected. As the mother of a toddler, I can only hope my son will view football as a spectator sport only!
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Ross Zafonte, DO, Senior Editor Commentary The role of the physiatrist in returning individuals to play carries substantial clinical implications. During the past decade, several criteria for the grading and treatment of concussion have been developed. These criteria are based on consensus statements and clinical examination findings; however, all lack physiologic correlates. Even the forces required to produce a concussion remain a controversy [1]. The implications of premature return can be devastating, and no clinician is ever completely sure an individual has been transparent in reporting all symptoms [2]. It is rather comforting to know that our 2 experts have taken a relatively similar approach to return of this young athlete. However, they do have somewhat-different approaches to the problem, with one having a greater focus on the guidelines and the other on clinical symptoms. In almost every case, critical clinical factors such as age, the previous number of concussions, sports career status, and timing of the season supplement the decision paradigm. Except for strongly compelling “special cases,” the recently published Zurich sports concussion consensus statement [3] includes the guidelines that at least present a reasonable path to follow. Neuropsychological testing before and after the incident remains a virtual gold standard, and few supplemental tests exist as clinically available tools. Perhaps in this case, balance testing electrophysiology might have yielded some additional information [4]. Further discussion is underway to evaluate physical markers such as soft neurological signs as an adjunct to neurocognitive testing. However, concerns
exist regarding the role of multiple exposures to concussion and long-term physiologic changes that occur as measured by magnetic stimulation [5]. Additional long-term concerns include the role of multiple minor traumas in the development of posttraumatic encephalopathy. Although no proven adjunct biologic testing yet exists, the movement toward physiologic metrics is necessary to further quantify risk and evaluate improvement. Even when such diagnostic tools are more readily available, they are unlikely to completely eliminate the emotional and clinical concerns involved in returning a successful athlete with multiple concussive exposures to play.
REFERENCES 1. Hamberger A, Viano D, Saljo A, Boloruri H. Concussion in professional football: Morphology of brain injuries in the NFL concussion model. Neurosurgery 2009;64:1174-1182. 2. Byard R, Vink R. The second impact syndrome. Forensic Sci Med Pathol 2009;5:36-38. 3. McCory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: The 3rd international conference on concussion in sport held in Zurich, November 2008. PM&R 2009;1:406-420. 4. Davis G, Iverson G, Guskiewcz K, Ptito A, Johnston K. Contributions of neuroimaging, balance testing electrophysiology and blood markers to the assessment of sports-related concussion. Br J Sports Med 2009;43: i36-i45. 5. DeBeaumont L, Theoret H, Mongeon D, et al. Brain function decline in healthy retired athletes who sustain their last sports concussion in early adulthood. Brain 2009;132:695-708.