Two of the best flag football teams in the country are meeting on the field of play early in a week-long national competition. The coaches, referees, and spectators do not notice an injury occur during the first half. At half time, one of the star players complains of a mild headache. The immediate concern for the sideline physician is to quickly assess for a concussion; and most people would turn to the Sideline Concussion Assessment Test (SCAT5) to evaluate the athlete. The current SCAT5 is recognized in the most recent concussion consensus statement as “the most well-established and rigorously developed instrument available for sideline assessment … [and] is useful immediately after injury in differentiating concussed from nonconcussed athletes.” This flag football athlete, who has a headache, unsteady gait, slight irritability, and cognitive impairment, seems to fit the diagnosis of concussion perfectly, and the SCAT5 results confirm the suspicion. The athlete should be held from play to allow complete brain recovery before return to contact sport and will likely miss the rest of the tournament, a difficult decision for a sideline physician to make on any sideline. However, this flag football star is competing at the Special Olympics USA Games and has an intellectual disability. His unsteady gait, slight irritability, and cognitive impairment were all present before the game. Now what?
The Special Olympics program supports more than five million athletes with intellectual disabilities in more than 170 countries. Athletes from around the world participate in more than 100,000 competitions each year in 32 Olympic type sports. More than 500,000 athletes compete in North America alone, and yet, we do not have a clear consensus or set of guidelines on concussion care of the athlete with an intellectual disability. A PubMed search for “sports-related concussion” limited to humans in the past 5 years identifies 762 publications. When the key word, “intellectual disability” is added to the search, the search results drop to zero. When the terms “Special Olympics” or “cognitive impairment” are used in addition to “sports-related concussion,” there also are no publications found. When the term “learning disability” is used, 15 publications are identified related to “sports-related concussions,” but none address concussion diagnosis or return to play.
The Special Olympics USA Games were held in Seattle, WA, in July 2018. A total of 2251 athletes from around the country participated in 14 different sports, including flag football, volleyball, soccer, and basketball, all sports that carry a risk of concussion. Over the course of the week, 47 athletes presented for medical attention with a chief complaint of headache, confusion, or concern for head injury. Thirteen of those athletes were diagnosed with concussion or possible concussion and counseled to return for follow-up before clearance. Most of these athletes were cleared on follow-up examination. All sideline medical providers were encouraged to balance the “overdiagnosis” of concussion in this athlete population with the risk of missing a concussion and putting the athlete at risk for further injury.
Given a lack of guidelines or criteria for determining medical eligibility, we required that all return-to-play decisions be made by experienced sports medicine physicians comfortable in concussion diagnosis and care.
For our flag football player, it was clear that the SCAT5 was not helpful. There were multiple reasons for a headache, including fatigue, heat, dehydration, and a new environment. The physician recommended that the athlete rest for the remainder of the game and return for an evaluation the following morning with a sports medicine physician. The athlete presented to the main medical area the following morning feeling much better. He had no headache, had rested, and was well hydrated. The physician spent more time with the athlete's coach, parent, and teammates than one would in a standard concussion assessment because these are the people who know him and his baseline best. He was cleared to return to play for the remainder of the tournament with guidelines to return for reevaluation with any recurrent symptoms. He played well with no return of his headache.
Assessing concussion in any athlete is difficult, and confounding conditions, like intellectual disability, further complicate the evaluation and return-to-play decision. Evaluating the whole athlete and incorporating the family and accompanying caregivers in a shared decision making model will likely lead to the best outcomes. The conundrum of relying solely on checklists and SCAT5, which will eliminate these athletes from competition for at least a week, if not more, and balancing the clinical assessment to allow competition, has challenging legal and ethical considerations. The potential for unintended bias to protect rather than risk return to play also is a factor. Future concussion guidelines and research related to sport concussions must address this growing population of Special Olympics athletes and other physically active individuals with intellectual disabilities to develop rational guidelines that will not automatically disqualify these athletes from competition.