Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players?
Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Am J Sports Med. 2011 Jun 28. [Epub ahead of print]
While many athletes suffering from a sports-related concussion typically recover within a week post trauma, there is a subset of athletes who tend to take longer to recuperate and return-to-play (RTP).  Recent evidence suggests that neurocognitive testing and subacute symptoms (2 to 3 days post trauma) may predict prolonged recovery (Lau BC et al 2011), but to date no research has evaluated whether on-field signs and symptoms could be predictors of a protracted recovery.  Therefore, Lau et al. sought to determine if on-field signs and symptoms were predictive of a prolonged concussion recovery (≥ 21 days) versus a short recovery (≤ 7 days).  For five years (2002 to 2006), high school football players were prospectively monitored for concussion that occurred during the pre- and/or regular seasons.  Concussions were determined by a certified athletic trainer and/or team physician based on the presence of one or more of the following on-field signs and symptoms post direct/indirect head impact: confusion, headache, loss of consciousness, post-traumatic amnesia, balance problems (assessed via Romberg, tandem walking, and heel-to-toe testing), dizziness, visual problems, personality changes, fatigue, sensitivity to light/noise, numbness, and vomiting.  Athletes were cleared to RTP by a sports medicine team member (i.e., certified athletic trainer, team physician, and neuropsychologist) when they were asymptomatic (at rest and post exertion), scored less than seven on the Post-Concussion Symptom Scale, and returned to baseline cognitive levels (determined via ImPACT).  During the five-year study period, 176 athletes sustained a concussion, but 69 were lost to follow-up, did not RTP, or did not RTP before the study ended.  Of the remaining 107 athletes, 62 exhibited a short recovery and 36 a prolonged recovery (9 athletes recovered between 8 to 20 days).  The researchers found that subjective declaration of dizziness during the on-field assessment was associated with prolonged RTP; however, over 89% of all concussed student-athletes, regardless of recovery time, experienced dizziness (73% of short recovery and 94% of prolonged recovery athletes).  Incidentally, the researchers observed a distinction from dizziness and balance problems (i.e., balance problems were not associated with prolonged RTP).          
This well-designed study is interesting because it demonstrated that on-field reports of dizziness, but no other on-field signs or symptoms, may identify athletes at risk for prolonged concussion recovery.  The potential of this early identification of athletes at-risk for prolonged recovery could allow for immediate, individualized care (e.g., close monitoring of athletes).  However, it should be cautioned that 73% of athletes with a short recovery also reported dizziness; but in this situation it may be helpful to be conservative.  It would be interesting if future studies evaluated athletes unable to return to play, accounted for athletes lost to follow-up, and utilized more sensitive balance tests (e.g., BESS) to clarify if dizziness is indeed a distinct symptom from balance problems.  In the meantime, the authors suggest that clinicians should assess dizziness (e.g., Dizziness Handicap Inventory) in addition to balance assessments (e.g., BESS).  What are your experiences with predicting which athletes may take longer than average to recover?   
Written by: Nieka Bright    
Reviewed by: Jeffrey Driban

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