Return to Play

Return-to-play decisions are driven by the concern of preventing potential complications, primarily second-impact syndrome and permanent neurologic deficit. Second-impact syndrome occurs when a player returns to play following a first concussion before the symptoms have completely resolved, and a second, often minor, blow to the head is sustained, which leads to diffuse cerebral swelling, brainstem hernia-tion, and death. The risk for catastrophic injury in athletes returned to play while still symptomatic is of particular concern in children and adolescents.

Long-term cognitive deficits from concussion or repetitive blows to the head are also a concern. Repetitive concussions, especially if severe, might put athletes at risk for permanent neurologic deficits (Guskiewicz et al., 2003). However, no evidence indicates that repetitive nonconcussive blows, such as those sustained from heading a soccer ball, lead to short-term or long-term neurologic impairment.

Most concussion guidelines designed to facilitate return-to-play decisions rely on loss of consciousness and the presence of amnesia to grade the severity of the concussion. This approach makes their usefulness limited because most sports-related concussions do not involve loss of consciousness or amnesia. Current recommendations suggest that management of concussion be based on symptoms and severity. The mildest concussion is one that involves transient symptoms that resolve quickly. More severe concussions involve persistent or prolonged symptoms and cognitive deficits on neuropsychological testing. Management of concussion includes both physical and mental rest, until all symptoms have cleared, and the neurologic examination, followed by a graded and stepwise program of exertion before return to sport (Box 29-4). Repetitive concussions, which take longer to return to baseline or that occur with progressively less trauma, are also considered of greater severity. Complex or recurrent concussions with persistent cognitive impairment, neurologic findings on examination, or prolonged symptoms may warrant advanced imaging and formal neuropsychological testing and should be managed by physicians with specific expertise in sports-related concussion.

Box 29-4 Graded Return to Play after Concussion*

1. Rest until asymptomatic

2. Light aerobic exercise (stationary cycling, slow jogging)

3. More strenuous aerobic training (running, sprinting)

4. Sport-specific training

5. Noncontact drills

6. Full contact drills

7. Return to competition

Modified from McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague, 2004. Br J Sports Med 2005;39:196-204.

*A player should never return to play while symptomatic from a concussion. In this supervised stepwise progression, the athlete can proceed to the next level if asymptomatic at the current level. If any postconcussion symptoms occur, the athlete should return to the previous asymptomatic level and try to progress again after 24 hours. Athletes with simple concussions may progress through these stages over several days. In cases of complex concussion, recovery is more prolonged.

Neuropsychological testing in concussion, initially a comprehensive battery of conventional written tests administered by a trained neuropsychologist, has evolved into a variety of computer assessment tools. These neuropsychological assessment tools are gaining acceptance in high-risk sports at the collegiate and professional levels and are most useful when there is a baseline assessment done before injury. Widespread use of these tests in youth and high school sports with limited budgets and medical personnel might not be practical.

In summary, concussion is a common injury in sport, and athletes sustaining a concussion should be medically evaluated by a physician. No symptomatic athlete should be allowed to return to play, and an athlete should not be allowed to return to play in the same game or practice during which an injury has occurred. Once asymptomatic, athletes should follow a graded program before return to play. Referral should be considered in complex or complicated concussions. Further research is needed to provide evidenced-based return-to-play guidelines and preventive strategies.

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