Return to play: 2017 concussion update

Elite skier and boarders are at high risk of concussion
WESTBOROUGH, MA December 20, 2017  There are no hard and fast rules for when athletes are permitted to return to the sport they love aside from the accepted practice that “same game” returns are not recommended. Some of these thoughts are brought forth from a post first published in 2013 about returning from concussion.  I have made updates to current accepted practices in concussion management.
In the beginning it was thought that athletes could return to play if they had only received a grade 1 concussion only and they had quickly returned to baseline. Many athletes were returned to play after sitting out just a few minutes or a single play allowing them time to recover their cognitive “senses”.  At a local presentation on concussion management presented to school parents, a custodian working in the school had stopped in to hear what I had to say. During the comments he told the audience that he had played football in high school – the same school for whom he was now working – and he had been returned to play 3 times in a single game after being knocked unconscious.  This was once thought to be a testament to his toughness.
The Boston Globe frequently features former athletes and the impact they now feel resulting from repeated concussions. Bob Hohler writes “head injuries at the time were treated as mere nuisances. Players reacted to violent head blows by trying to blink away their blurred vision, shake the ringing from their skulls, and trundle back to their huddles, unless they were flagged by sideline doctors.  Even then, they generally returned quickly to action.”
This is no longer the standard of care for concussion management.  Especially the grading system is no longer recognized and individual athletes are assessed using sideline tests that measure cognitive functions such as concentration, memory, and orientation.  In the big leagues the athlete is taken to a quiet area off the field to rest and be evaluated by the team physician or concussion expert.  The NFL now has people in the stands who are told to watch for players who may have had their brain injured – like signs of poor balance, confusion, or an inability to focus on the game.  Teammates are now expected to report concussions to their coaches.
Return to play should be carefully managed by the team physician and trainer.  The school nurses are expected to participate in a significant piece of the return to school protocol by providing support, a rest stop when needed, counseling, and often re-testing.  I speak to many school nurses and have the greatest respect for them.  They are the front line for all kinds of high school malaise.
No player should go from zero percent play to 100 percent play without monitored, “symptom free” exertion.  In the context of youth sports, my program at Whittier Rehabilitation Hospital in Westborough, MA offers preseason training and support to coaches, parents, and players about concussion and the consequences of returning to the game before being fully healed.  As with other medical history, it is a good idea to have an idea which athletes may be more vulnerable to concussion before competition begins.
Generally, pediatricians are becoming better educated about both the risk and consequence of concussion.  For the longest time the responsibility for releasing an athlete to return to play was solely the pediatricians call.  This has changed across New England since 2009.  Returning to play after concussion requires a stepwise process. Each step is monitored by a trainer, coach or volunteer with training in concussion.  Athletes must remain asymptomatic at each phase of their return before they are released to 100 percent full contact at game speed.  This is not always easy to arrange as many school districts have no athletic trainer or share the services of an athletic trainer among several sports.  Athletes are followed during recovery with exertion testing and should not play if they are at all symptomatic.  In cases where no physician or trainer are available coaches and parents often supervise the specific exertion protocol outlined by the physician or concussion specialist.  I spend a fair amount of time teaching the re-exertion steps necessary for safe return-to-play.  A specific return to play protocol outlining gradual increase in physical activity has been established by the Concussion in Sport Group (Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell, McCrory, Meeuwise, Schasmasch, 2001. Clinical J. Sports Med.).
There is a subset of athletes whose recovery will not follow this protocol because of previous concussions – especially those with a prior history of concussion, ADHD, learning disability, and depression.

Hohler, B (2017) Big men broken minds. Boston Globe October 28, 2017.

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