Furthermore, best practice recommendations by the NCAA include the establishment of clear communication of roles among health care providers involved with the athletic team. Although the sports medicine physician generally will make the ultimate decisions on care, recognition of each provider’s scope of legal and professional practice to make decisions is necessary. Furthermore, care should be based on a baseline symptom checklists, cognitive and balance assessments, and neuropsychological testing (32).
CONCUSSION MANAGEMENT: ASSESSMENT
A concussion evaluation consists of the evaluation of somatic, cognitive, and emotional symptoms, physical signs, behavior changes, cognitive impairment, and sleep disturbances (29). The foundation of concussion management is a symptom assessment. Symptoms are assessed immediately after a concussion is suspected and then routinely reassessed throughout the recovery and return-to-play process (15).
The most commonly used instrument for identifying and tracking the presence and severity of symptoms is a graded symptom checklist, similar to that proposed by the National Athletic Training Association’s position statement on concussion in sport (15). In like fashion, a symptom evaluation is included in a component of the Sport Concussion Assessment Tool 2 (SCAT2). The SCAT2 was developed in 2008 by the International Conference of Concussion in Sport and openly disseminated for public use (30). It was revised in the 2012 International Conference of Concussion in Sport in 2012 to the SCAT3 (29). This tool incorporates both the symptom evaluation and the cognitive and physical evaluation (see Supplemental Digital Content 1, http://links.lww.com/SCJ/A117).
The number and type of symptoms that initially occur have been found to impact one’s recovery. A study by Makdissi et al. (25) found that delayed return to sport correlated with the presence of 4 or more symptoms and reports of fatigue and fogginess. In addition, the authors found that those athletes who had complaints of headache lasting for more than 60 hours to be delayed in their ability to return to sport, and conversely, those who had complaints of headache less than 24 hours returned to sport sooner.
The motor domain of neurological function is assessed through postural stability (balance) assessments. It has been shown that balance deficits typically last up to 72 hours after a concussion episode (14). Assessment of postural stability can be performed through either sophisticated balance systems or a reliable clinical test, such as the balance error scoring system test (10).
In addition to symptom assessment and physical (balance) assessments, additional cognitive function assessment through neuropsychological testing has become commonplace in assessment and management. Neuropsychological testing is now recommended by many professional sports organizations, the National Athletic Training Association (15), and specifically identified by the CISG as contributing to the comprehensive evaluation of concussion (29). It has been shown that recovery of full cognitive function through neuropsychological testing often follows symptom resolution (1,25). Thus, in the absence of neuropsychological testing, return-to-play decisions should be more conservative. Standardized neuropsychological tools are available and becoming widely used, such as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and CogState. These tests have been validated, shown good reliability (35,36), and have added significant value to concussion assessment. In a study by Van Kampen et al. (41) researchers found an increase in the sensitivity of concussion detection from 64% to 83% with the addition of ImPACT to the assessment process compared with the diagnosis on the use of symptoms alone. In a study by Makdissi et al. (25), researchers found that 35% of their athletes measured as having “impaired” cognitive status based on computerized testing 2–3 days after full symptom resolution. These studies further support a conservative approach to management.
Through reviewing these categorical assessments, it can be discerned how concussion assessment is multifaceted, involving trained professionals with differing backgrounds, such as athletic training, sports medicine, and neuropsychology. The management of athletes recovering from a sports concussion and return-to-play process is equally interdisciplinary. The comprehensive assessment and management plan should take special consideration in the analysis of the aforementioned tests in relation to baseline assessments. All athletes, whether elite or nonelite, are recommended to have baseline assessments, and this information should guide return to activity (29).
MANAGEMENT: RETURN TO PLAY
The cornerstone of concussion management is physical and cognitive rest (29). Physical rest is achieved through removal from all physical activity, not only competition but also all forms of exercise. Cognitive rest involves both academic and nonacademic behaviors. Athletes should refrain from schoolwork, leisure reading, and other activities that require concentration and attention such as video games (24). These periods of rest should last until symptom resolution (15,29,32). It is important that practitioners should ensure an athlete to be asymptomatic before engaging in any exercise program.
Once an athlete is asymptomatic, the sports medicine team should initiate a graduated return-to-play program. This program consists of 6 stages with the recommendation that athletes have a period of 24 hours between each stage. Thus, according to these recommendations by the third International Conference on Concussion in Sport (29), an athlete should not return to play until at least 1 week after symptoms have resolved. During each phase, the athlete is monitored for signs and symptoms of postconcussion, such as headache, fatigue, fogginess, and the like. After participation in each phase, a symptom checklist should be completed. If symptoms are present, the athlete rests for 24 hours and then reverts back 1 phase. The recommended graduated return-to-play program by the CISG is presented in Table 4.
It is the recommendation of the authors of this article that dosing of exercise during the return-to-play program is fully discussed with the managing physician and/or sports medicine team because there may be confounding factors to be considered such as history of repeat concussions, severity of the recent concussive episode, or previous symptoms during recovery. If an athlete is progressed too rapidly through the return-to-play program or returns to full competition prematurely, there may be significant consequences. Athletes recovering from concussion who are progressing too rapidly may develop prolonged symptoms and mental health issues such as depression. Even more significantly, athletes who return quickly may be at risk of developing second impact syndrome or eventually chronic traumatic encephalopathy (28). It should be noted that in the 2012 International Conference on Concussion in Sport, the CISG unanimously agreed that no return to play on the same day of a concussive injury should occur (29).
Per the return-to-play protocol, athletes should initiate exercise only when asymptomatic. Exercise begins in a light aerobic fashion, with the intensity below 70% of the maximum predicted heart rate. No specific duration is provided by the recommendations (29), nor is it provided in many university athletics protocols or by the NCAA (32). In addition to previously discussed factors, it is reasonable to believe that dosing may include some specificity related to sport-specific factors. It is also very important in this stage that heavy resistance training is avoided because of the potential for increased intracranial pressure (8). It seems the primary mechanism causing increased intracranial pressure during resistance training is performance of the Valsava maneuver (33). The tendency to perform a Valsava maneuver for many individuals is common during their heaviest lifts. Therefore, using lighter weight will decrease the likelihood of an athlete performing the maneuver and avoid the negative consequences of increasing intracranial pressure in this population.
The next stage of the return-to-play protocol is the sport-specific phase. This phase focuses on adding functional movements, which may include activities such as gentle cutting and/or agility tasks to aerobic activities from the previous day. There will also be a low level of cognitive interaction during these functional, sport-specific drills. However it should be noted that heavy resistance training and excessive anaerobic stresses are still avoided at this point.
Progression of the athlete to the next phase should include noncontact training drills with aims to add greater cognitive stress and coordination to the exercise prescription. In addition, this phase allows for heavier resistance training, which can increase intracranial pressure. As intensity of these drills increase, anaerobic stresses can be added to the drills or through normal exercise prescription.
Full-contact practice is the final step to returning to competition. This is a vital phase because it allows normal contact drills, which will likely include activities that caused the concussion. This phase is only entered with medical clearance, and only the sports medicine physician, in consultation with the sports medicine and strength and conditioning teams, should clear the athlete for full return to play.
Return to play should be a decision that is multifaceted and not reliant on any one variable. Consistent with the return-to-play recommendations by the CISG (29), additional factors have been proposed to guide an athlete’s return to play, which include the following (24):
- Athlete must be asymptomatic at rest
- Athlete must be asymptomatic during and after full cognitive and physical exertion
- Balance/postural stability must return to baseline
- Neuropsychological/cognitive testing must return to baseline.
ADDITIONAL CONSIDERATIONS FOR THE STRENGTH AND CONDITIONING PROFESSIONAL
As strength and conditioning professionals interact with athletes after concussion, it is imperative that open communication is standard practice. All members of the sports medicine and strength training teams must be aware of the recovery process of each individual athlete. In addition, it is essential that there is open communication of any additional confounding factors. Athletes with repeat concussion history may be placed at risk for prolonged recovery. In addition, it has been shown that females have an increased duration of recovery and severity of symptoms (5,6). Thus, they are more likely to become symptomatic during physical exertion during the return-to-play protocol. In a similar manner, younger athletes are slower to recover cognitively compared with college and professional athletes (6,9,37).
In addition to these factors, all members of the sports medicine and strength and conditioning teams must be cognizant of modifiers to the graduated return-to-play protocol. These modifiers were presented by the third International Conference on Concussion in Sport and are included in Table 5 (29).
Strength and conditioning professionals are very likely to encounter athletes who have had a recent concussion and are likely to interact with athletes shortly after a concussion incident. Because strength and conditioning professionals are also typically involved in preseason assessments, they may be involved with some of the baseline data collection procedures as well. As a result of their close interactions with athletes throughout season and offseason training, the strength and conditioning professional must understand when an athlete is presenting with postconcussive symptoms and should be evaluated by a member of the medical team. Not only are strength and conditioning professionals in positions to witness events that could cause concussive episodes, but also they have routine interaction with athletes and thus are in position to recognize abnormal behaviors or signs and symptoms consistent with concussion. Common occurrences that may lead to cause for referral to an appropriate medical provider are as follows:
- Witnessing a significant impact and reaction in the athlete that could lead to suspicion of a concussion (loss of consciousness, unsteadiness, etc).
- Communications with athletes during conditioning time may suggest that they have an altered cognitive status or balance.
- Communication with other teammates may give insight that another athlete received a particularly hard blow or is showing symptoms, which are not consistent with their normal behavior.
- Observation of athletes during a conditioning program, which promotes suspicion, including forgetfulness, difficulty with visual focus, or difficulty following directions.
Should the strength and conditioning professional note any of these considerations a referral is necessary. Findings should be communicated to the medical team, which often includes the athletic trainer and sports medicine physician. Specific signs and symptoms should be noted and the circumstances surrounding the occurrences of the symptoms should be communicated (time, location, activity). It is imperative that these findings be communicated as soon as possible. Practice and training activities can be hectic times, and a lack of communication could subject the athlete to further trauma.
Concussion assessment and comprehensive management including return to play requires active participation and monitoring of an interdisciplinary team. Athletic trainers, physicians, other sports medicine providers, and strength and conditioning providers will interact with athletes as they recover from concussive events. In addition, with the levels of underreporting or diminished monitoring in less organized sports and recreational activities, it is possible that strength and conditioning professionals will be the first to encounter individuals with concussive symptoms. A working knowledge of the etiology of concussion, awareness of signs and symptoms, and understanding of best practices for the management of sports concussion is necessary, so proper referrals and interactions with sports medicine providers can lead to the best care of their clients.
1. Bleiberg J, Cernich AN, Cameron K, Sun W, Peck K, Ecklund PJ, Reeves D, Uhorchak J, Sparling MB, Warden DL. Duration of cognitive impairment after sports concussion. Neurosurgery 54: 1073–1080, 2004.
2. Bull RJ, Cummins JT. Influence of potassium on the steady-state redox potential of the electron transport chain in slices of rat cerebral cortex and the effect of ouabain. J Neurochem 21: 923–937, 1973.
3. Buzzini SR, Guskiewicz KM. Sport-related concussion in the young athlete. Curr Opin Pediatr 18: 376–382, 2006.
5. Colvin AC, Mullen J, Lovell MR, West RV, Collins MW, Groh M. The role of concussion history and gender in recovery from soccer-related concussion. Am J Sports Med 37: 1699–1704, 2009.
6. Covassin T, Elbin RJ, Harris W, Parker T, Kontos A. The role of age and sex in symptoms, neurocognitive performance, and postural stability in athletes after concussion. Am J Sports Med 40: 1303–1312, 2012.
7. Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The epidemiology of sport-related concussion. Clin Sports Med 30: 1–17, 2011.
8. Dickerman R, McConathy W, Smith G, East J, Rudder L. Middle cerebral artery blood flow velocity in elite power athletes during maximal weight-lifting. Neurol Res 22: 337–340, 2000.
9. Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 142: 546–553, 2003.
10. Finnoff JT, Peterson VJ, Hollman JH, Smith J. Intrarater and interrater reliability of the balance error scoring system (BESS). Am J Phys Med Rehab 1: 50–54, 2009.
11. Gerberich SG, Priest JD, Boen JR, Straub CP, Maxwell RE. Concussion incidences and severity in secondary school varsity football players. Am J Public Health 73: 1370–1375, 1983.
12. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athlete Train 42: 495–503, 2007.
13. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athlete Train 36: 228–235, 2001.
14. Guskiewicz K. Postural stability assessment following concussion. Clin J Sport Med 11: 182–190, 2001.
15. Guskiewicz KM, Bruce SL, Cantu RC, DFerrara MS, Kelly JP, McCrea MM, Putukian M, McLeod TC. National Athletic Trainers’ Association position statement: Management of sport-related concussion. J Athlete Train 39: 280–297, 2004.
16. Hootman J, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athlete Train 42: 311–319, 2007.
17. Hovda DA, Yoshino A, Kawamata T, Katayama Y, Becker DP. Diffuse prolonged depression of cerebral oxidative metabolism following concussive brain injury in the rat: A cytochrome oxidase histochemistry study. Brain Res 567: 1–10, 1991.
18. Hubschmann OR, Kornhauser D. Effects of intraparenchymal hemorrhage on extracellular cortical potassium in experimental head trauma. J Neurosurg 59: 289–293, 1983.
19. Jinguji TM, Krabak BJ, Satchell EK. Epidemiology of youth sports concussions. Phys Med Rehabil Clin N Am 22: 565–575, 2011.
20. Katayama Y, Becker DP, Tamura T, Hovda DA. Massive increases in extracellular potassium and the indiscriminate release of glutamate following concussive brain injury. J Neurosurg 73: 889–900, 1990.
21. Koh JO, Cassidy JD, Watkinson EJ. Incidence of concussion in contact sports: A systematic review of the evidence. Brain Inj 17: 901–917, 2003.
22. Langlois JA, Rutland-Brown W, Thomas KE. The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil 20: 229–238, 2005.
23. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: A brief overview. J Head Trauma Rehabil 21: 375–378, 2006.
24. Ma R, Miller CD, Hogan MV, Diduch BK, Carson EW, Miller MD. Current concepts review: Sports-related concussion: Assessment and management. J Bone Joint Surg Am 94: 1618–1627, 2012.
25. Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR. Natural history of concussion in sport: markers of severity and implications for management. Am J Sports Med 38: 464–471, 2010.
26. Mayevsky A, Chance B. Repetitive patterns of metabolic changes during cortical spreading depression of the awake rat. Brain Res 65: 529–533, 1974.
27. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: Implications for prevention. Clin J Sport Med 14: 13–17, 2004.
28. McCrory P, Makdissi M, Davis G, Turner M. Sports concussion. In: Clinical Sports Medicine (4th ed). Brukner P, Kahnn K, eds. Sydney, Australia: McGraw-Hill Australia Pty Ltd, 2012. pp. 273–289.
29. McCrory P, Meeuwisse W, Aubry M, Cantu RC, Dvorak J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Bensen BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator C, Turner M. Consensus statement on concussion in sport: The 4th International Conference on concussion in sport, held in Zurich, November 2012. Br J Sports Med 47: 250–258, 2012.
30. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu RC. Consensus statement on concussion in sport: The 3rd international conference on concussion in sport held in Zurich, November 2008. J Athlete Train 44: 434–448, 2009.
31. Meehan W, d’Hemecourt P, Comstock R. High school concussions in the 2008-2009 academic year. Am J Sports Med 38: 2405–2409, 2010.
32. National Collegiate Athletic Association. Concussion or mild traumatic brain injury in the athlete. In: 2011-2012 NCAA Sports Medicine Handbook. Indianapolis, IN: National Collegiate Athletic Association, 2011. pp. 53–58.
33. Niewiadomski W, Pilis W, Laskowska D, Gąsiorowska A, Cybulski G, Strasz A. Effects of a brief Valsalva manoeuvre on hemodynamic response to strength exercises. Clin Physiol Funct Imaging 32: 145–157, 2012.
34. Rosenthal M, LaManna J, Yamada S, Younts W, Somjen G. Oxidative metabolism, extracellular potassium and sustained potential shifts in cat spinal cord in situ. Brain Res 162: 2113–2127, 1979.
35. Schatz P. Long-term test-retest reliability of baseline cognitive assessments using ImPACT. Am J Sports Med 38: 47–53, 2010.
36. Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol 21: 91–99, 2006.
37. Sim A, Terryberry-Spohr L, Wilson KR. Prolonged recovery of memory functioning after mild traumatic brain injury in adolescent athletes. J Neurosurg 108: 511–516, 2008.
38. Takahashi H, Manaka S, Sano K. Changes in extracellular potassium concentration in cortex and brain stem during the acute phase of experimental closed head injury
. J Neurosurg 55: 708–717, 1981.
39. Thurman DJ, Branche CM, Sniezek JE. The epidemiology of sports related traumatic brain injuries in the United States: Recent developments. J Head Trauma Rehabil 13: 1–8, 1998.
40. Tommasone BA, McLeod TC. Contact sport concussion
incidence. J Athlete Train 41: 470–472, 2006.
41. Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med 34: 1630–1635, 2006.
Keywords:© 2013 by the National Strength & Conditioning Association
sport concussion; head injury