Sports Medicine Research: In the Lab & In the Field: Are We Assessing and Managing Concussions Properly? (Sports Med Res)
Tuesday, October 25, 2011

Are We Assessing and Managing Concussions Properly?

Assessment and Management of Sport-Related Concussions in United States High Schools

Meehan WP, d’Hemecourt P, Collins CL, Comstock RD. Am J Sports Med. 2011 Oct; ahead of print
http://www.ncbi.nlm.nih.gov/pubmed/21969181

There are several different concussion assessment tools (e.g., SCAT2, BESS, Headminder) to evaluate an athlete, however, little research is done on what medical professionals use to assess concussions. The purpose of this study was to describe the medical providers and medical studies used when assessing sport-related concussions, as well as, to determine the effects of medical provider type on timing of return to play, frequency of imaging, and frequency of neuropsychological testing. This study followed 192 U.S. high schools with at least one full time athletic trainer during the 2009 to 2010 academic year. The results showed that nearly 15% (1,056) of the athletic injuries were concussions. Boys’ contact sports had the highest number of concussions per 100,000 athletic exposures (i.e., football, ice hockey, and lacrosse). Most of the concussion (53%) took place during a varsity contest, and grade level was about the same (freshman 25.8%, sophomore 25.1%, juniors 22.7%, seniors 23%). The most commonly reported sign and symptoms were headache (94%), dizziness (76%), difficulty concentrating (54%), and confusion (44%). Most athletes had resolution of symptoms within 7 days (78%), but 2.8% had symptoms lasting within a month. Nearly, 93% of the time there was a medical professional on the scene at the time of the concussion, where athletic trainers were there 70% of the time. However, there was no significant difference found between having a medical professional at the scene of the injury and duration of symptoms or return to play time. Out of all the recorded concussions an athletic trainer assessed 94%, 59% were evaluated by a physician, and 5% were evaluated by an orthopedic physician. Most were assessed by more than one medical professional (87% assessed by athletic trainer and physician). Computed tomography (CT) was used in 21% of the concussed athletes, where only 3% received magnetic resonance imaging (MRI). Return to play decisions were commonly made by an athletic trainer (46%) or a physician (50%), but there was still almost 3% getting cleared by nonmedical professionals like coaches. Athletes whose symptoms took longer to resolve (over 7 days) were seen more often by a physician.

It is imperative the medical professionals know how to handle and manage sports-related concussions. Though, few studies have been done to evaluate who and what tests are evaluating concussive injuries. This epidemiologic report did find that most of the concussions were first evaluated by an athletic trainer; however, this study only included schools that had at least one full time athletic trainer on staff. Many schools in the U.S. still do not have a full time athletic trainer, and it would be advantageous to investigate these schools. Also, 60% of the athletes were evaluated by a physician that does not specialize in treating athletic injuries. Although, return to play time was not significantly different between athletic trainers or physicians, this suggests that both use similar evaluation tools. However, the actual tools that the medical professionals used were not reported. Finally, this study revealed that 1 and 5 concussed athletes receive a CT as part of the evaluation process, but these concussions do not usually involve structural damage that can be seen in a CT. MRIs are radiation free and are more sensitive in detecting concussions. This study demonstrates the need for general physicians to continue their education in concussion injuries due to the common occurrence of these injuries. Also, future research should consider specifying what type of concussion tests are being used for diagnosis and treatment. Specifically, what tests are being used at the site of the injury; what tests are being used in the athletic trainer room, and what tests are general physicians using? Current concussion literature states that a battery of tests [i.e., concussion sign and symptom survey, SCAT2, BESS, and a computerized exam (e.g., ImPACT, Headminer)] are sensitive enough to evaluate a concussion, however there have been no studies done on what is actually being practiced especially within a general physician’s office.

Written by: Jane McDevitt MS, ATC, CSCS
Reviewed by: Stephen Thomas





Meehan Iii WP, d'Hemecourt P, Collins CL, & Comstock RD (2011). Assessment and Management of Sport-Related Concussions in United States High Schools. The American Journal of Sports Medicine PMID: 21969181

6 comments:

Nicole Cattano said...

Jane-this is a great post that is very pertinent now. I have heard of several issues with family doctors clearing athletes to play a day or two after injury despite an athletic trainer telling the athlete that they should not play. It seems that there is a lag on the general medical practitioners' knowledge and management of this issue. With all of the media covering concussions, its amazing to see this still happening! And it puts clinicians in a very tough position.

Jane McDevitt said...

Nicole, You are so right. I believe it does put the clinicians in a tough positions as well as the Athletic Trainers. However, even if the physician clears the athlete to play they should not be returned to full functional play, but a gradual return. In this way Athletic Trainers can gain control over the return to play of an athlete especially in cases where the physician may clear the athlete to quickly. Also, the physician and athletic trainer should have good communication over injuries and could implement standing orders for how they manage a concussion as a team. If the athletic trainer is up to date with the concussion management we can hopefully prevent and second impact problems that can arrise from returning an athlete to play to quickly. It is the schools with no athletic trainer that is becomes very problematic.

Erica Beidler said...

Jane and Nicole- I would have to agree that good communication between health-care providers and up-to-date knowledge on concussion management are both key aspects in achieving the desired outcomes for return to play following a mTBI.

While at the NATA convention last summer, I attended the concussion series that addressed return to play in high school athletes. The progression that was presented focused heavily on return to education before return to athletics.
It was proposed that following a concussive event, the student-athlete should be removed from athletics and school. Time at home should be spent sleeping and relaxing (not watching tv, texting, videogaming, or reading) in order to promote a healing environment for the brain. Once the individual is symptom free for 24 hours, a progressive return to academics begins (homework at home -> ½ day of school -> full day of school). After full academic demands are met without recurrence of symptoms, then a gradual return to athletics is permissible.

I am in full support of this concussion management protocol. In my opinion, it addresses an important issue that other return to play guidelines forget about, academics. High school and college individuals are student-athletes…not athlete-students right? Education should always come first.

This return to play procedure could potentially increase time loss for athletes, but this is one situation where I think the positives of a slower return to play progression outweigh the negatives. In the big picture, which is more important…participating in a high school athletic game or graduating with honors? Overall, I think that it would be helpful to have a standardized assessment tool and concussion management protocol to take all guessing out of the equation.

Nicole Cattano said...

Erica, I think it would be a great idea to implement concussion management plans. I attended the same speakers at NATA, and here at PATS we had a similar message. Mickey Collins addresses this in depth, the issue is getting buy-in from the academic side for something that they cannot see/measure. Have you implemented anything at your clinical site?

Anonymous said...

Erica,

I agree with you fully. I believe we are getting closer to a protocol that would allow ATCs to assist in athletes safe return into school. Like Nicole had mentioned, I have also attended one of Dr. Collins' clinics and he does a great job of explaining the reasoning and education you have to give parents and teachers to allow additional time off for concussed students. This is also a great site to reference called brain steps funded through the PA department of education. I think they also do a great job of explaining the steps of returning an concussed athlete back to school (http://www.brainsteps.net/_orbs/about/).

Jane McDevitt said...

Erica,

I agree with you fully. I believe we are getting closer to a protocol that would allow ATCs to assist in athletes safe return into school. Like Nicole had mentioned, I have also attended one of Dr. Collins' clinics and he does a great job of explaining the reasoning and education you have to give parents and teachers to allow additional time off for concussed students. This is also a great site to reference called brain steps funded through the PA department of education. I think they also do a great job of explaining the steps of returning an concussed athlete back to school (http://www.brainsteps.net/_orbs/about/).

Post a Comment

When you submit a comment please click 'Subscribe by Email" (just below the comments) or "Subscribe to: Post Comments (Atom)" (at the bottom of this page) if you would like to receive a notification when another comment has been submitted to this post.

Please note that if you are using Safari and have problems submitting comments you may need to go to your preferences (privacy tab) and stop blocking third party cookies. Sorry for any inconvenience this may pose.