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Evaluation of the Zurich Guidelines and Exercise Testing for Return to Play in Adolescents Following Concussion

Darling, Scott R. MD*; Leddy, John J. MD*; Baker, John G. PhD*,†; Williams, Amy J. MA; Surace, Anthony MEd*; Miecznikowski, Jeffrey C. PhD; Willer, Barry PhD§

Clinical Journal of Sport Medicine: March 2014 - Volume 24 - Issue 2 - p 128–133
doi: 10.1097/JSM.0000000000000026
Original Research

Objective: To evaluate return to play (RTP) and return to classroom outcomes when the Zurich guidelines are combined with a standardized exercise treadmill test [Buffalo Concussion Treadmill Test (BCTT)] and computerized neuropsychological (cNP) testing in adolescent athletes after concussion.

Design: Retrospective chart review and follow-up.

Setting: University Sports Medicine Concussion Clinic.

Participants: One hundred seventeen athletes (75% male) with sport concussion ages 13 to 19 years and telephone follow-up of 91 (77.8%) athletes and their parents.

Interventions: Concussed athletes who were asymptomatic at rest completed Automated Neuropsychological Assessment Metrics or Immediate Post-concussion Assessment and Cognitive Test cNP testing followed by the BCTT on the same day. Athletes then followed the Zurich consensus guidelines for RTP.

Main Outcome Measures: The primary outcome measure was the degree of success in RTP, that is, RTP with or without return of concussive symptoms. Secondary outcome measure was return to school with or without symptoms.

Results: All athletes returned to sport without exacerbation of symptoms. Telephone follow-up revealed that 38.5% experienced new issues upon return to the classroom. Forty-eight percent of athletes had 1 or more cNP subtests below average (<ninth percentile) when asymptomatic. Ultimately, performance on cNP was not predictive of return to school issues.

Conclusions: The BCTT in combination with the Zurich consensus guidelines seems to be safe and successful for RTP. There is evidence to suggest that cNP testing performed in athletes who do not have a preinjury baseline test was not related to RTP or problems upon return to school.

*Departments of Orthopaedics;

Nuclear Medicine;

Biostatistics; and

§Psychiatry, University at Buffalo, Buffalo, New York.

Corresponding Author: Scott R. Darling, MD, Department of Orthopaedics and Sports Medicine, University at Buffalo, 160 Farber Hall, Buffalo, NY 14214 (

The authors wish to thank the following organizations for financial support of the project described in this article: The Robert Rich Family Foundation, Program for Understanding Childhood Concussion and Stroke, Buffalo Bills (Ralph Wilson) Team Physician Fund and the Buffalo Sabres Foundation.

The authors report no conflicts of interest.

Received October 22, 2012

Accepted September 10, 2013

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