Return To Competition After Sportrelated Concussion

Over the past two decades, a number of grading scales for severity of concussion and return to play have been proposed.4,6,8-14 The lack of consensus among experts lies in the fact that few of the scales or guidelines are derived from conclusive scientific data but rather developed from anecdotal literature and clinical experience. The Cantu evidence-based grading scale (see Table 14-2) is currently recommended because it emphasizes all signs and symptoms, without placing too much weight on LOC and amnesia. This scale should be used to grade the injury only after the athlete is declared symptom free, as duration of symptoms is important in grading the injury. No athlete should return to participation while still symptomatic.

The question of return to competition after a head injury is handled on an individual basis, although conservatism seems the wisest course in all cases. The athlete whose confusion resolves promptly (20 minutes) and has no associated symptoms at rest or during or following functional testing may be considered a candidate to return to play. Any LOC should eliminate a player from participation that day. Table 14-12 offers a guide to making restricted and unrestricted return-to-play decisions following concussion. The following factors should also be considered when making decisions regarding an athlete's readiness to return following head injury:

1. Athlete's history of concussion.

2. The sport of participation (contact versus noncontact).

3. Availability of experienced personnel to observe and monitor the athlete during recovery.

4. Early follow-up to determine when a disqualified athlete can return to participation.

5. Repeated assessment should be the rule. The athletic trainer and team physician must be assured that the athlete is asymptomatic before a return to participation is permitted. This can be done through the use of neu-ropsychological testing and postural stability assessment.

6. Any athlete who has experience LOC should not be permitted to return to play on that day.

7. Any athlete with a concussion that evolves downward should be sent for neurologic evaluation and/or hospital admission.

Athletes who are unconscious for a period of time or those who have headaches require evaluation and monitoring by a physician. Although the majority of people with head trauma recover without any permanent neurologic deficit or need for surgery, head trauma can be very serious and perhaps life threatening. Several guidelines have been proposed for return to play following multiple head injuries in the same season.4,8,9 Most experts agree that athletes should be held from competition for extended periods of time (1 to 3 additional weeks) following a second concussion to ensure that all postconcussive symptoms

Table 14-12 Guidelines for Return to Play after Concussion*

Mild

Remove from contest. Examine immediately and at 5-min intervals for development of abnormal concussive symptoms at rest and with exertion. May return to contest if examination is normal and no symptoms develop for at least 20 minutes.

If any symptoms develop within the initial 20 minutes, return on that day should not be permitted.

If the athlete is removed from participation as a result of developing symptoms, follow-up evaluations should be conducted daily. May return to restricted participation when the athletic trainer and team physician are assured that the athlete has been asymptomatic1 at rest and with exertion for at least 2 days, followed by return to unrestricted participation if asymptomatic for 1 additional day. Neuropsychological assessment and balance/coordination testing are valuable criteria, especially if preseason baseline measures are available.

Moderate

Remove from contest and prohibit return on that day. Examine immediately and at 5-min intervals for signs of evolving intracranial pathology. Re-examine daily. May return to restricted participation when the athletic trainer and team physician are assured that the athlete has been asymptomatic at rest and with exertion for at least 4 days, followed by return to unrestricted participation if asymptomatic for an additional 2 days. The performance during restricted participation should be used as a guide for making the decision for unrestricted participation. Neuropsychological assessment and balance/coordination testing are valuable criteria, especially if preseason baseline measures are available.

Severe

Treat on field/court as if there has been a cervical spine injury. Examine immediately and at 5-min intervals for signs of evolving intracranial pathology. Re-examine daily. Return to play is based on how quickly the athlete's initial symptoms resolve:

1. If symptoms totally resolve within the first week, athlete may return to restricted participation when the athletic trainer and team physician are assured that the athlete has been asymptomatic at rest and with exertion for at least 10 days, followed by return to unrestricted participation if asymptomatic for an additional 3 days.

2. If symptoms fail to totally resolve within the first week, athlete may return to restricted participation when the athletic trainer and team physician are assured that the athlete has been asymptomatic at rest and with exertion for at least 17 days, followed by return to unrestricted participation if asymptomatic for an additional 3 days.

The performance during restricted participation should be used as a guide for making the decision for unrestricted participation. Neuropsychological assessment and balance/coordination testing are valuable criteria, especially if preseason baseline measures are available.

*Refer to Table 14-2 for grade/level.

1 Asymptomatic means that the athlete has returned to baseline scores on the Graded Symptom Checklist. Any second concussion sustained within a 3-month period of the first concussion requires that the athlete rest for twice the maximum number of days recommended for the respective severity level.

have resolved and that participation in contact sports should be terminated for the season after three concussions.

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