By Vernon B. Williams, MD
Effective concussion programs require action prior to a concussion ever occurring (Pre-Season/Pre-Concussion). There are other protocols and actions required at the time a concussion occurs (Acutely). Still more specific actions, policies, and procedures involve sub-acute, and sub-chronic concussion management and appropriate return to play.
Preseason/Pre-Concussion Clinical Care Essentials
Pre-season and Pre-concussion protocols are critical. There are 3 main components of this aspect of concussion clinical care. They include: Game-Planning, Education, and Baseline Testing.
Game-Planning: Rules and regulations are rapidly changing to accommodate the evolving understanding of concussion risk. Individual sports governing bodies, leagues, and states are responding to concerns regarding concussion from a regulatory standpoint. An understanding of changed rules and regulations as well as how the changes and additions apply to the population of athletes involved is paramount. An accurate and realistic assessment of resources available for implementation of the game-plan is essential. An operational plan and documentation of the planned clinical workflow is advisable and should be part of the game-plan. Questions to be answered include who reports injuries to whom, how injuries are to be reported, how quickly injured athletes will be assessed, at what intervals they are to be re-assessed, what specific tools are to be used for baselining and re-assessment, who ultimately clears an athlete for return to play, how communication and how documentation will be handled.
Education: Athletes need meaningful and effective pre-season counseling and education. Critical elements include a discussion of relative concussion risk and instruction in how to recognize when they or a teammate is exhibiting signs and symptoms of concussion. They also need pre-season education regarding the steps to be taken and criteria for return to play. The same is true for trainers, coaches, parents, spouses/significant others, school officials, and administrators. Athletes will typically under-report symptoms in an effort to “tough it out”, “hang in there”, and “be there for the team.” This education is critical in developing buy-in and agreement with philosophy that is most likely to result in compliant behavior. Effective education must change an athlete’s temptation and tendency to under-report symptoms and to achieve pre-mature return to play. Effective education must change trainer and coach’s temptation to ignore guidelines, bend reporting or return to play rules, or influence athlete’s to “shake it off”, “walk it off”, and return to play prematurely.
Baseline Testing: A concussion history should endeavor to document the number, severity, and characteristics of any previous concussions (both sports and non-sports-related). A history of any neurological diagnoses should be obtained and documented as well as any history of migraine in the athlete or first-degree relatives. A history of any behavioral diagnoses, and/or learning disability should be obtained as well. A baseline assessment of symptoms (symptom score) and a targeted neurological examination is a necessary part of the pre-season assessment with special attention to documentation of balance/coordination as well as cognitive function.
Acute Clinical Care Essentials
Clinical care of acute concussion involves assessment of ABC’s (airway, breathing, and circulation). Most importantly, it involves the ability to assess any need for emergency Neurosurgical or Spine Surgery intervention.
Red Flags: Presence of prolonged loss of consciousness (lasting greater than one minute), a neurological abnormality on examination, evidence of spine or skull fracture, vomiting, or deteriorating mental status should result in immediate transport to emergency department for appropriate imaging and treatment.
Players with signs and symptoms of concussion should not be allowed to return to play in the same day. Athletes who are not referred for emergency department assessment should be released to the care of a responsible adult who has been provided appropriate information and education regarding concussion. There should be clear communication of what signs and symptoms for which they should be vigilant and any red flags that should result in emergency department evaluation.
Post-Concussion Care and Return to Play Essentials
Education: Every interaction with a concussed athlete represents an opportunity for education. The education can represents a form of treatment, in that anxiety and concern regarding symptoms can contribute to escalation of disability and adversely affect recovery, particularly when the symptoms are unexplained and/or misunderstood by the athlete and/or others concerned with their wellbeing. Reassurance regarding the frequency of and reason for symptoms, education regarding the unique and individual characteristics contributing to severity and duration of symptoms, and review of the protocol and rationale for steps leading to safe return to play can be a therapeutic intervention.
Symptom Evaluation and Management: Each interaction with the concussed athlete should include an updated symptoms assessment that can be compared to baseline/pre-season assessments and any previous assessments. Athletes should be encouraged to be as honest and objective as possible. Accuracy will be directly related to athlete “buy-in” regarding the overall process and the education provided on an ongoing basis throughout their evaluation and management process. While rest and restriction from physical activity is strongly recommended in the acute post-concussion phase, other management techniques are more nuanced and individualized. Restriction from school in the name of “cognitive rest” is infrequently indicated and may have significant negative consequences. However, in many cases, academic accommodations (reduced work load, extra time for assignments, untimed tests, etc.) are indicated. Watchful waiting has been replaced by active surveillance and active intervention in the evaluation and treatment of symptoms. Headache management, cervical spine evaluation and management, vestibular and visual assessment with rehabilitation when appropriate are increasingly applied in the post-concussion “symptom management” phase. As well, there is developing evidence that after the acute phase, controlled exertion and neural activation may be more beneficial than persistent and continued rest and restriction from any physical activity.
Return to Play: A generally held belief is that there should be individualized recommendations for each unique athlete, rather than dependence on rigid and often arbitrary timelines for return to play. The athlete should be symptom-free in the absence of medications used to control or manage symptoms (i.e., off all headache medications, etc.). Other criteria include normal examination and return to baseline on cognitive and balance testing. When cleared for return to play, there should be explicit instruction in gradual, step-wise progression of activity as tolerated, rather than immediate return to full activity. The initial step should target assessment of the athlete’s ability to tolerate aerobic exercise without exacerbation of symptoms. This step is followed by progressive increase in the intensity of aerobic activity and addition of non-contact sports-specific activities. This step ensures assessment of coordination and safe, efficient functional movement. The next two steps involve allowing the athlete to progress to performance of their normal sports activities. This should occur first in a practice-environment with eventual clearance for competition/game play if tolerated. A player must demonstrate ability to tolerate each step without return or exacerbation of symptoms and signs prior to progression to the next step. The progression and step-wise return has no absolute time frame. It may occur over the course of days, weeks, or longer and is based on the athlete’s individual and unique clinical course and resolution.
It should be noted that concussion is a complex brain injury that can affect a wide variety of neurological functions and result in a myriad of potential symptoms and signs. The clinical care is often challenging. In cases of prolonged and severe symptoms and when community resources permit, it is often useful to employ an interdisciplinary approach to evaluation and management. A concussion care team might include a Neurologist, Neuropsychologist, Physical Therapist, and consulting subspecialists (Ophthalmology/Optometry, ENT, Spine, Pain Management, Psychology/Psychiatry, Sleep), if indicated. In other environments, access to related subspecialties and healthcare practitioners might be limited and require a concussion “generalist”. In both cases communication between all clinicians involved in clinical care as well as communication with trainers, personal physicians, other team physicians (Orthopedic Surgery), parents, coaches, and school officials (in the case of student athletes) is also an important.
About the Author: Vernon B. Williams, MD is a Sports Neurologist and Pain Medicine Physician. He is the Founding Director, Center for Sports Neurology at the Kerlan-Jobe Orthopedic Clinic in Los Angeles, California, the Director of Pain Medicine at the Kerlan-Jobe Orthopedic Clinic, the Founding Director of the Sports Neurology Fellowship at the Kerlan-Jobe Center for Sports Neurology and the Chief Medical Officer of the Sports Concussion Institute. Dr. Williams serves as consultant to the Los Angeles Lakers, Los Angeles Dodgers, Los Angeles Kings, Los Angeles Sparks, Anaheim Ducks, Loyola University, Fullerton College, and numerous high schools. He completed his Pain Medicine Fellowship at Johns Hopkins. He is a frequent speaker on sports neurology, concussion, and pain. Dr. Williams is an experienced expert witness and independent medical examiner.