Return to play following sports-related concussion
Section snippets
Definition of concussion
Despite hundreds of studies and years of research, there is currently no universally accepted definition of concussion. However, for the past three decades the definition originally proposed by the Committee on Head Injury Nomenclature of Neurological Surgeons in 1966 has by far represented the most popular definition. This committee defined concussion as “a clinical syndrome characterized by the immediate and transient post-traumatic impairment of neural function such as alteration of
Pathophysiology of concussion
Recent research into the subtle metabolic effects of concussion has triggered burgeoning insights into the pathophysiology of concussion. Using a rodent model, Hovda and colleagues [5] have described a metabolic dysfunction that occurs when cells immediately injured upon concussive insult are exposed to dramatic changes in both their intracellular and extracellular environments. These changes are the result of excitatory amino acid–induced ionic shifts with increased Na/KATP-ase activation and
On-field and sideline management of concussion
The diagnosis of cerebral concussion can be tricky under the best of circumstances. There may be no direct trauma to the head, and the concussed athlete is infrequently rendered unconscious. The athlete may be unaware that they have been injured immediately after the injury and may not show any obvious signs of concussion such as clumsiness, gross confusion, or obvious amnesia. To complicate the situation, athletes at all levels of competition may minimize or hide symptoms in an attempt to
Initial sideline signs and symptoms of evaluation and return to play
Box 1 provides a summary of common on-field signs and symptoms of concussion. It should be stressed that sideline presentation may vary widely form athlete to athlete, depending on the biomechanical forces involved, specifically affected brain areas, prior history of injury, and numerous other factors. In reviewing the common signs and symptoms of concussion, it is imperative to note that an athlete may present with only one symptom or potentially a myriad of symptoms. A thorough assessment of
On-field evaluation of mental status and markers of concussion
Appropriate acute care of the concussed athlete begins with an accurate assessment of the gravity of the situation. As with any serious injury, the first priority is always to evaluate the athlete's level of consciousness and ABCs (airway, breathing, and circulation). The attending medical staff must always be prepared with an emergency action plan in the event that the evacuation of a critically head- or neck-injured athlete is necessary. This plan should be familiar to all staff, well
Recent research on predictors of outcome following concussion
Two published studies exist examining on-field predictors of outcome following sports-related concussion. Collins and colleagues [10] investigated the relationship between on-field markers of concussion severity and postinjury neurocognitive performance and symptom presentation in a group of 78 concussed high school and college athletes. Data from this study revealed that the presence of amnesia, not brief loss of consciousness, was most predictive of postinjury difficulties at 3 days
Return to play guidelines
During the past 30 years, over 20 concussion management guidelines have been published with the intent of providing guidance and direction for the sports medicine practitioner in making complex return to play decisions [1]. These guidelines also provide accompanying grading scales designed to reflect and characterize the severity of the injury. Although these guidelines have no doubt resulted in improved care of the athlete, these multiple directives also create significant confusion and spark
Individual factors determining return to play
Once a concussed athlete has been removed from a game, the sports medicine physician is faced with the often challenging decision of when the athlete is safely able to return to play. Making return to play decisions, both on the field and during the postinjury management of injury (ie, days after injury) in athletes can be one of the most complex decisions facing the sports medicine physician and represents a dynamic process that involves the evaluation of factors such as the severity of the
Neuropsychologic testing
The development of neuropsychologic testing as a diagnostic tool in sports medicine is a relatively recent development that initially took place in the mid-1980s within the context of a large, multisite research project undertaken by Barth and colleagues [27] at the University of Virginia. This study demonstrated the potential use of neuropsychologic test procedures to document cognitive recovery within the first week following concussion. However, this study did not result in the widespread
Approaches to computer-based neuropsychologic testing
Presently there are several computer-based management approaches under development to help provide the sports medicine clinician with neurocognitive data to better determine return to play and other management issues following concussive injury [33]. Specifically, four computer-based models have been detailed in the scientific literature. These include ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) CogState, Headminders, and ANAM (Automated Neuropsychological Assessment
A clinical model for computerized neuropsychologic testing
The University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program represents a specialized clinical and research program that uses neurocognitive testing to assist in general concussion management issues (eg, determining return to play, retirement decisions, and so forth). This program uses the ImPACT computer-based neuropsychologic testing program [10], [20], [21], [26]. This test battery was developed to address the inherent limitations of traditional neuropsychologic
Other neurodiagnostic techniques
Although neuropsychologic testing has increasingly been used as both as a research and clinical tool, the past several years have witnessed the emergence of an intense focus on the development of sophisticated brain imaging techniques. This interest grew out of new technologic advances in brain imaging in addition to frustration regarding the well-known lack of sensitivity of more traditional anatomic imaging techniques such as CT and MRI. Although useful in identifying brain injury in more
University of Pittsburgh Medical Center Sports Concussion Program: protocol for return to play
Based on recent research regarding recovery from concussion and the Vienna international consensus statement [16], the UPMC return to play protocol involves the graduated return to play of the athlete to competition based on his or her progression through several steps in the recovery process. First and foremost, we feel strongly that athletes who have either abnormal neuropsychologic test results or are symptomatic should not be returned to play following injury until they are asymptomatic and
Conclusions and future directions
This article has focused on new developments in the management of sports-related concussion. Specifically, we have emphasized that the clinical management of concussion is evolving rapidly, and we still have much to learn about both the short- and long-term consequences of injury. As increasingly more research studies are designed to investigate the biomechanics, pathophysiology, and clinical course of sports-related concussion, our management strategies will continue to evolve over the next 5
References (36)
- et al.
Physiological and pathophysiological roles of excitatory amino acids during central nervous system development
Brain Res Brain Res Rev
(1990) - et al.
Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes
J Pediatr
(2003) - et al.
Differential working memory load effects after mild head injury
Neuroimage
(2001) - et al.
Current issues in managing sports concussion
JAMA
(1999) - et al.
The assessment of sports-related concusions: the evidence behind neuropsychological testing and management
Clin J Sport Med
(2001) Committee on head injury nomenclature: glossary of head injury
Clin Neurosurg
(1966)Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee
Neurology
(1997)- et al.
Neurobiology of concussion
- et al.
Cerebral hyperglycolsis following severe human traumatic brain injury: a positron emission tomography study
J Neurosurg
(2003) - et al.
New frontiers in diagnostic imaging in concussive head injuries
Clin J Sport Med
(2001)
Second impact syndrome: a risk in any sport
Phys Sportsmed
Relationship between post-concussion headache and neuropsychological test performance in high school athletes
Am J Sports Med
On-field predictors of neuropsychological and symptom deficit following sports-related concussion
Clin J Sport Med
Symptom-based assessment of the severity of concussion
J Neurosurg
Cerebral concussion in sport: management and prevention
Phys Sportsmed
Concussion in sports: guidelines for the prevention of catastrophic outcome
JAMA
Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play
J Athletic Training
Concussion in sports
Am J Sports Med
Cited by (112)
Vestibular rehabilitation following head injury
2023, Otologic and Lateral Skull Base TraumaBeliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population
2020, Archives of Physical Medicine and RehabilitationSport concussion
2020, Brain Injury Medicine: Board ReviewTraumatic Brain Injury
2020, Braddom's Physical Medicine and RehabilitationVision disorders in mild traumatic brain injury
2019, Neurosensory Disorders in Mild Traumatic Brain InjuryTraumatic Brain Injury
2018, Braddom's Rehabilitation Care: A Clinical Handbook