Sports concussion: A return-to-play guide

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Applied Evidence

Sports concussion: A return-to-play guide

J Fam Pract. 2012 June;61(6):323-328

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References

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9. American Academy of Neurology. Position statement on sports concussion. October 2010. AAN policy 2010-36. Available at: http://www.aan.com/globals/axon/assets/7913.pdf. Accessed February 23, 2011.

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11. Herring SA, Cantu RC, Guskiewicz KM, et al. Concussion (mild traumatic brain injury) and the team physician: a consensus statement—2011 update. Med Sci Sports Exerc. 2011;43:2412-2422.Available at: http://journals.lww.com/acsm-msse/Fulltext/2011/12000/Concussion__Mild_Traumatic_Brain_Injury__and_the.24.aspx. Accessed February 23, 2011.

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CASE Our neurologic examination yielded normal results. However, our patient was unable to balance correctly on one leg. The cognitive exam revealed a deficit in short-term memory. We diagnosed a concussion, advised her to refrain from sports, and prescribed cognitive rest. A return to school for half days would be considered once her symptoms began to resolve.

TABLE 1
Signs and symptoms commonly associated with concussion

Headache “Pressure in head” Neck pain Nausea or vomiting Dizziness Blurred vision Balance problems	Sensitivity to light Sensitivity to noise Feeling slowed down Feeling like “in a fog” “Don’t feel right” Difficulty concentrating Difficulty remembering	Fatigue or low energy Confusion Drowsiness Trouble falling asleep Irritability Sadness Nervousness or anxiety
Adapted from SCAT2 in Appendix 1 of: McCrory P, Meeuwisse W, Johnston K, et al. Br J Sports Med. 2009;43(suppl 1):i76-i90.¹²

Options for the neurologic exam
With a simple concussion, expect a normal neurologic examination, with the possible exception of the ability to balance. Head imaging is not necessary in the setting of suspected concussion, because results of computed tomography (CT) and magnetic resonance imaging (MRI) will likely be normal.¹²

Balance testing can assist in the diagnosis of concussion and the monitoring of recovery from injury.^15-17 The Balance Error Scoring System (BESS)¹⁵ is a validated and simple test that can be done in the office. The test involves 3 consecutive stances: (a) normal stance with feet comfortably apart and hands on hips, (b) with feet aligned heel to toe with the dominant leg in front, and (c) standing on the nondominant leg with the dominant leg flexed 30 degrees at the hip. Have the patient repeat each version of the test for 20 seconds with eyes closed, on a stable and then unstable surface (eg, foam mat).

It’s recommended that another staff member be present to spot the patient in case of a fall. A link to a complete description of the test and scoring details is provided in the Web resources box.

Assess cognitive function. One tool for assessing cognitive function is the Sports Concussion Assessment Tool 2 (SCAT2).¹² SCAT2 includes newer, as yet unvalidated sections and several sections that have been independently studied and proven useful in diagnosing concussion. Validated sections are the Maddocks questions, used only at the time and place of injury¹⁸; the modified BESS¹⁵; and the Standardized Assessment of Concussion (SAC).¹⁹ The SCAT2 and the SAC (which may be used separately) include questions that assist in evaluating short-term memory and attention, and are useful in the physician’s office.

Do computer-based tools help? Another option for cognitive assessment is computer-based neuropsychologic testing developed specifically for use with suspected concussion. Any of these programs can be used in the office by a trained practitioner. Schools may also use the programs under the supervision of an athletic trainer or team physician. Available programs are ImPACT, developed by the University of Pittsburgh (http://impacttest.com); the Cognitive Stability Index (CSI), by HeadMinder (http://www.headminder.com/site/csi/home.html); and the Computerized Cognitive Assessment Tool (CCAT), by CogState/Axon Sports (http://www.axonsports.com). Multiple studies have shown such programs to be useful in diagnosing and monitoring recovery from sports concussion.^20-23

However, among sports medicine practitioners, there seems to be a consensus that computer-based neuropsychologic testing is most useful when a baseline score exists. Baseline testing is usually done preseason on athletes in a healthy state. If a baseline score is not available, a patient’s postinjury score is compared with normative data produced by the developer of the individual test.

FAST TRACK

Evaluate a patient using the Balance Error Scoring System, and, for cognitive function, the Standardized Assessment of Concussion or a similar tool.

Few, if any, outcome studies have been conducted to determine whether computer-basedneuropsychologic testing provides any meaningful improvement in the care of athletes who have suffered concussions. There is also concern that few studies by independent sources have replicated the data disseminated by developers of the tests.^24,25 The most recent guidelines by the 3rd ICCS recommend using neuropsychologic testing only as an aid to an overall medical evaluation, not as the sole determinant of recovery from concussion.¹² Numerous studies now underway may help clarify the role of neuropsychologic testing in concussion.

CASE By the time of our follow-up exam 7 days later (11 days from injury), KD had returned to school for half days, but her phonophobia and headaches worsened at school and she had difficulty focusing on academic tasks. Neurologic, balance, and cognitive exams were all normal. We advised her to gradually return to school full time while abstaining from sporting activity.