Concussion Management: Proper Protocol
It is the hot-button topic in sports safety today, although it really always should have been. Concussions – more specifically the effects of them, if you have read the harrowing tales of how so many have suffered , including former NFL stars Dave Duerson and Fred McNeill – are clearly no longer a matter of “having your bell rung” and being “tough enough” to keep playing.
All of this makes proper concussion management and testing that much more paramount.
Because when it comes to concussion management, a cautious approach is the only approach.
According to 2012 research documented by The American Orthopaedic Society of Sports Medicine, concussion injuries occur at a rate of 0.14-3.66 per 100-player seasons at the high school level, or 3-5 percent of injuries in all sports. Professional sports leagues like Major League Baseball (7-day concussion disabled list) and the National Football League (moving back kickoffs to the 35-yard line) have joined the efforts to curtail concussions.
However, concussions still do happen. When they do, your team physician can help the athlete, starting with on-field, sideline, and post-game evaluation, and treatment.
DIAGNOSIS
A team physician takes several things into account when diagnosing a concussion: How the injury was caused, all immediate symptoms, using a SCAT (Sports Concussion Assessment Tool) 2 questionnaire, and neurocognitive tests.
Once a concussion is diagnosed, the athlete will not be allowed to return to play.
Doctors not only perform detailed testing to determine the initial severity of the injury (i.e. whether or not there is a loss of consciousness, a neurological deficit, if the injury affects the spine), but they then proceed to obtain a more-detailed history and go more in-depth with their physical examination of each athlete treated. Doctors evaluate Cognitive (confusion, delayed motor and verbal responses, inability to focus, loss of consciousness), Somatic (blurred vision, fatigue, headache, nausea/vomiting), and Affective (irritability and emotional liability, or instability) symptoms.
From there, as team physicians, it is important that doctors stay with the athlete to monitor symptoms, and continually evaluate and re-evaluate symptoms. After the game, doctors give the athlete, the team trainer, coaches, and families post-event instructions regarding medications, physical exertion and, most importantly, a follow-up appointment.
When a patient visits a doctor after experiencing a concussion, we speak to their family about their observations. Doctors discuss the athlete’s progress with their coaches and trainers because we believe everyone should be involved in the overall care of the athlete.
MANAGEMENT
First and foremost, doctors should evaluate symptom resolution. As the patient’s symptoms resolve, they will begin to undergo a return-to-play (RTP) protocol that will include a gradual increase in activity. The athlete will be monitored through each phase of activity while being evaluated for symptoms.
There are six stages, lasting at least 24 hours per stage.
- Cognitive and physical rest until asymptomatic
- Light aerobic exercise
- Heavy aerobic exercise
- Sport-specific exercise
- Non-contact drills; light resistance training
- Full-contact training if medically cleared
The athlete only progresses to the next stage if asymptomatic. If symptoms occur with exertion, they will either return to the previous stage or rest for an additional 1-3 days.
Once asymptomatic, an ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) Test will be performed. While there are multiple neurocognitive tests available, ImPACT is the most widely used and scientifically accredited computerized concussion evaluation system utilized by all Major League Baseball and National Hockey League teams, as well as 24 National Football League teams including the New York Giants and Jets.
The athlete will be monitored on a daily basis by the athletic trainer and team physician. Only once the athlete is symptom-free and has completed the ImPACT evaluation, the team physician will make a decision about clearing the athlete to return to competition.
RTP GUIDELINES
A reputable doctor will provide athletes and coaches with a stringent concussion management plan that delineates comprehensive RTP guidelines.
The RTP criteria will take the patient’s symptoms, neurocognitive testing, and post-injury testing into consideration in order to make a clear decision.
Each athlete’s RTP is individualized — and not based upon a pre-determined timeline — because each athlete recovers differently based upon factors including, but not inclusive of age, previous concussions, and severity of current concussion.
Because when it comes to concussion management, a cautious approach is the only approach.
Located at 1111 Paulison Ave. in Clifton, orthopaedic surgeon and sports medicine specialist Dr. Michael C. Russonella and primary care sports medicine specialist Dr. Manik Singh of the North Jersey Orthopaedic & Sports Medicine Institute serve as team physicians for the Belleville and Bloomfield high school athletic departments.
