- Author: David T Bernhardt, MD; Chief Editor: Craig C Young, MD more...
Return to Play
Return-to-play criteria are controversial. Similar to classification guidelines, several different guidelines regarding return to play have been established. No scientific evidence exists to justify one criterion versus another criterion. The main criteria for an athlete's return to play include complete clearing of all symptoms, complete return of all memory and concentration, and no symptoms after provocative testing. Provocative testing includes jogging, sprinting, sit-ups, or push-ups—in other words, some type of exercise that raises the athlete's blood pressure and heart rate.
The rules are the same for athletes who have a concussion that prohibits return to play during competition. Only after all symptoms have cleared both at rest and with exertion should an athlete even consider returning to practice or competition. In addition, the athlete has to show complete resolution of any emotional lability, mood disturbance, attention, or concentration difficulty. Relatively minor concussions may have more prolonged neurologic deficits. Therefore, the most important aspect of all published guidelines is the concept of an athlete not being allowed to return to play until he/she is completely asymptomatic.
A study of high school concussion patients reports that most assessments are performed by athletic trainers and the timing of return to play was similar whether the decision was made by a physician or an athletic trainer.
In 2010, the AAN issued a brief position statement on sports concussion, recommending caution and protection first. If an athlete is suspected of having a concussion or closed head injury, then first remove the athlete from practice or competition, and do not allow return to play until he or she is evaluated by a physician with experience in treating concussions and cleared for return. Further recommendations are available in the 2013 AAN guidelines on evaluation and management of sports concussion.
See Postconcussive Syndrome, above (in the Treatment, Acute Phase, Medical Issues/Complications section).
Injury prevention methods are currently being studied. In the past, rule changes that barred spearing in football and teaching football players not to lead with their head have significantly reduced the frequency of severe head injuries in American football.
Equipment and environmental changes can also prevent injury. Soccer goals must be anchored to the ground because many deaths secondary to head injury in soccer have been the direct result of a goal tipping over onto a player.
There is controversy regarding possible helmet wearing in soccer. Although helmets have been shown to clearly reduce the risk of head injury in recreational bicycle riding, no clear evidence exists that the type of headgear proposed for youth soccer will prevent acute or chronic head injury among soccer players. Long-term studies that examine soccer players over time and that compare the players to themselves in a longitudinal fashion have not been completed. Thus far, studies that suggest long-term damage from heading have been methodologically flawed by comparing soccer players to other athletes, and these studies have not been able to distinguish heading from previous concussions. Most concussions in soccer are the result of direct contact rather than heading of the ball.
Even if helmets are used, no guarantee exists that they will necessarily fit. Studies of football helmet use in high school have demonstrated that only 15% of the helmets fit properly. Further documentation of the possible increase in the risk of head injury associated with poor helmet fit has not been completed.
Although mouth guards have been advocated for injury prevention purposes, no controlled study has proven their usefulness in concussion prevention.
Most patients with an MTBI are able to return to full competition without complication. Because many patients may not report minor head injuries to the athletic trainer, emergency department (ED), or a primary care physician, the overall prognosis of many head injuries is unclear.
A study including male high school football players noted that dizziness at the time of injury is associated with an increased risk of protracted (≥21 d) recovery. Another study involving athletes aged 9-23 years with a diagnosed protracted concussion found that those who have vestibular symptoms after concussion may have slower reaction times than those who do not and thus may be at greater risk for new injury.
A study by Ling and colleagues indicated that at least 4 months after an MTBI, the brain continues to display signs of damage, even if the clinical symptoms of injury have subsided. Evaluation of patients with mild brain injury, however, revealed no evidence of cortical or subcortical atrophy. The study involved 50 patients with MTBI and 50 matched controls. In the first 2 weeks following injury (the semiacute injury phase), patients with concussion complained of more cognitive, somatic, and emotional symptoms than did the controls. These symptoms, however, were significantly reduced at 4-month follow-up (at which time, 26 of the patients were evaluated).[66, 67]
In a prospective cohort study of 280 patients aged 11 to 22 years who presented to an emergency department with acute concussion, repeat concussions increased the risk for prolonged recovery. Patients with a history of previous concussions had symptoms that lasted twice as long (24 days) as those who did not have such a history (12 days).
An analysis of children presenting to the ED with concussion showed that the patients were still struggling with a significant burden of symptoms 1 week after injury.[69, 70] Headache was the most common initial symptom; by day 7, 69.2% were still experiencing headaches. Fatigue persisted in 59.8% of children at day 7, and poor concentration persisted in 56.8% 1 week later. Emotional symptoms (eg, depression, frustration, irritability, and restlessness) also developed and increased by day 7 but were largely resolved by day 90.
Chronic postconcussive syndrome can be quite severe, with the most dramatic presentation including dementia pugilistica, which is associated with boxing. This Alzheimer-like condition has a reported incidence of 15% among professional boxers. Fortunately, this condition is rare in most other sports. Hopefully, more frequent, detailed neuropsychologic testing will decrease the frequency of postconcussive syndrome among elite and professional athletes by detecting more subtle injuries earlier. For further information on this topic, see Repetitive Head Injury Syndrome.
It is important to educate allied health professionals, coaches, families, and athletes about the recognition and acute management of a concussion, the difficulties involved with a concussion, the difficulty in managing and treating concussions, and the subtle problems with long-term complications. Understanding and recognition of these issues by all of the above may help to prevent recurrent concussion problems. Inexperienced healthcare providers may want to use some type of published guideline when initially managing these injuries.
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