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Greater awareness of the potential long-term sequelae from multiple concussions has prompted nearly two-thirds of states to pass legislation that is meant to protect athletes suspected of having a concussion.
These laws are spurring wider use of concussion screening tests and educational materials to inform coaches, parents, athletes, and medical professionals of the importance of identifying players suspected of having a concussion and getting them evaluated before they can return to play. Studies also are underway or being planned to determine how the risk of concussion varies among individuals and how it is influenced by the number and severity of blows to the head.
Since the enactment of the Lystedt Law in Washington in 2009, 29 other states and the District of Columbia have passed similar laws, and an additional state has a bill that at press time awaited the governor’s signature for final passage into law, according to NFL Health & Safety. In general, the laws require that athletes suspected of having a concussion be held out of games or practice until they have been evaluated and cleared to return by a trained and licensed health care provider, whose definition varies across states.
These developments are driving a change in attitude toward how concussions are evaluated and managed at all levels of sports, both in practice and on the field. "What we’re starting to see is organizations taking a look at practice parameters, [such as] limiting the amount of contact that can happen in the practice environment," said Dr. Jeffrey S. Kutcher, director of the University of Michigan’s Neurosport Program. He noted that this year the Ivy League conference became the first to limit the amount of contact that players have during practice sessions.
Return to play is now being more widely regarded as a medical decision that must be made by qualified health care providers. In a position paper last year, the American Academy of Neurology (AAN) said that return-to-play decisions should be made by a neurologist or a physician with training in the evaluation and management of sports concussion. It also called for certified athletic trainers to be present at all sporting events and practices at which athletes are at risk of concussion.
Recognizing Concussion in Youth Athletes
But while professional sports teams and universities can provide physicians or athletic trainers to screen for and diagnose concussion, youth athletes most often won’t have those resources available. They need people trained to screen for concussion and pull them out of play until they can be evaluated by a licensed health care provider.
"[High] schools are not going to have a physician on the field," Dr. H. Hunt Batjer, professor and chair of neurological surgery at Northwestern University, Chicago, said in an interview. In the metro Chicago area, "many do not have close affiliation with a trainer. Somebody is going to have to take on that role of identifying a concussed athlete. Ideally, it would not be the coach. Ideally, it would be a health professional."
To help youth and high school coaches – as well as athletes and parents – recognize the signs of concussion and know what to do to if a player gets a head injury, the AAN is offering two free, online, 20-minute safety courses created by the University of Michigan’s Neurosport Program. Free downloadable cards that describe how to spot concussion and what to do if one occurs also are available on the academy’s website.
How to Evaluate Concussion
There are at least 16 different grading systems that attempt to measure severity of traumatic brain injury (TBI), the most recent about 10 years old, according to Dr. Michael A. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.
However, the AAN is developing a new grading system that "will probably be published by November of this year. That will be very useful and most updated based on class I evidence," noted Dr. Lobatz, who spoke at a meeting on primary care medicine sponsored by the Scripps Clinic.
Older grading systems do not properly prognosticate the severity of the concussion and duration of symptoms. They also fail to appreciate the sensitivity of children and adolescents to concussion, who are at higher risk than adults are for second-impact syndrome, and they are slower to recover than adults, Dr. Richard Ellenbogen, professor and chair of neurological surgery at the University of Washington, Seattle, said in an interview.
Rather than grade the level of concussion, "it’s more important to define and describe the symptoms and signs that they were suffering that were indicative of a concussion, so you can follow those," Dr. Ellenbogen said.
Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask them what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."
Sorting out preinjury vs. postinjury factors in patients with concussion is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."
Returning to Play Postinjury
Return to play is not advised if athletes are still experiencing symptoms of a concussion. If they return before they’re fully healed and suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."
Dr. Batjer emphasized that the most important elements of return to play criteria include managing the athlete’s concussion in a quiet, nonstimulating environment; being asymptomatic at rest and during exertion; clearance from the team trainer or doctor; and clearance from an independent health care provider skilled in the treatment of concussion.
To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment that provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-i84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full-contact practice, and eventual return to play.
Alternative Concussion Tests
Many other alternative tests are available, Dr. Kutcher noted, including the Axon Sports Computerized Cognitive Assessment Tool, the HeadMinder Concussion Resolution Index, and CNS Vital Signs. However, he cautioned that such tests often provide a false sense of security.
"It is the nature of neurological examination that it is not very easily put into check boxes and protocols. Doing a neurologic examination is an organic process, and so while these tools are good places to start and provide a framework for evaluation, they should never be thought of as being a complete evaluation," he explained.
The new National Football League sideline concussion assessment protocol that was announced last February draws on elements of a screening tool that was recommended in the consensus statement from the Third International Conference on Concussion in Sport, the SCAT2 (Sport Concussion Assessment Tool 2), which was modified for football. It includes a focused screening neurologic examination to exclude cervical spine and intracranial bleeding, as well as assessments of orientation, immediate and delayed recall, concentration, and balance.
The protocol is designed to "create a little more homogeneity in the way players are assessed on the field" but is not meant to "ever replace the professional judgment of a team physician or trainer on the field," said Dr. Ellenbogen, who cochairs the NFL Head, Neck, and Spine Committee with Dr. Batjer.
The Future of Concussion Treatment
Future decisions on the field of play will depend in part on the conclusions of studies designed to determine what factors increase the risk of concussion and long-term neurologic deficits in different individuals. But such studies have many methodologic challenges.
"One of the problems is people are trying to connect the dots by looking retrospectively and saying ‘You played X number of years at this position and you tell me you had this many concussions,’ and trying to use that as a definition of exposure when that is fraught with all kinds of bias and ambiguity," said Dr. Kutcher, chair of the AAN’s Sports Neurology Section. "There are efforts now at different levels to try to track players prospectively. But one of the problems there is, what are you going to track as the exposure? Right now, it is the number of concussions, but that is clearly not the whole picture. You need to be tracking the number of hits.
"If we’re ever going to make decisions on whether somebody gets to play or not based on the number of hits they’ve taken, we should have a clear scientific understanding of what those hits are doing, and we don’t," Dr. Kutcher said. "There’s a general concept that the types of hits that athletes take during contact sports can’t be good for the brain. The real question is, how bad is it? The underappreciated aspect of this is how individual that answer is. If you took 100 players and gave them the same type and number of exposures over a lifetime, you’re going to get 100 different results."
Several planned studies sponsored by the NFL, the Department of Defense, and the National Institutes of Health will evaluate new football helmet designs and test accelerometers inside them to measure the frequency and force of hits in relation to the players’ neurologic status. Other studies are proposing to compare a group of age- and position-matched former NFL players with players who played at the collegiate level and control subjects who did not play sports, according to Dr. Batjer.
In another study, Dr. Kutcher said that he and investigators from the University of North Carolina at Chapel Hill and the University of California, Los Angeles, will track the longitudinal neurologic status of players of both genders in sports with and without helmets (using accelerometer-instrumented mouth guards) throughout their career and afterward against control subjects.
Doug Brunk contributed to this report.
Greater awareness of the potential long-term sequelae from multiple concussions has prompted nearly two-thirds of states to pass legislation that is meant to protect athletes suspected of having a concussion.
These laws are spurring wider use of concussion screening tests and educational materials to inform coaches, parents, athletes, and medical professionals of the importance of identifying players suspected of having a concussion and getting them evaluated before they can return to play. Studies also are underway or being planned to determine how the risk of concussion varies among individuals and how it is influenced by the number and severity of blows to the head.
Since the enactment of the Lystedt Law in Washington in 2009, 29 other states and the District of Columbia have passed similar laws, and an additional state has a bill that at press time awaited the governor’s signature for final passage into law, according to NFL Health & Safety. In general, the laws require that athletes suspected of having a concussion be held out of games or practice until they have been evaluated and cleared to return by a trained and licensed health care provider, whose definition varies across states.
These developments are driving a change in attitude toward how concussions are evaluated and managed at all levels of sports, both in practice and on the field. "What we’re starting to see is organizations taking a look at practice parameters, [such as] limiting the amount of contact that can happen in the practice environment," said Dr. Jeffrey S. Kutcher, director of the University of Michigan’s Neurosport Program. He noted that this year the Ivy League conference became the first to limit the amount of contact that players have during practice sessions.
Return to play is now being more widely regarded as a medical decision that must be made by qualified health care providers. In a position paper last year, the American Academy of Neurology (AAN) said that return-to-play decisions should be made by a neurologist or a physician with training in the evaluation and management of sports concussion. It also called for certified athletic trainers to be present at all sporting events and practices at which athletes are at risk of concussion.
Recognizing Concussion in Youth Athletes
But while professional sports teams and universities can provide physicians or athletic trainers to screen for and diagnose concussion, youth athletes most often won’t have those resources available. They need people trained to screen for concussion and pull them out of play until they can be evaluated by a licensed health care provider.
"[High] schools are not going to have a physician on the field," Dr. H. Hunt Batjer, professor and chair of neurological surgery at Northwestern University, Chicago, said in an interview. In the metro Chicago area, "many do not have close affiliation with a trainer. Somebody is going to have to take on that role of identifying a concussed athlete. Ideally, it would not be the coach. Ideally, it would be a health professional."
To help youth and high school coaches – as well as athletes and parents – recognize the signs of concussion and know what to do to if a player gets a head injury, the AAN is offering two free, online, 20-minute safety courses created by the University of Michigan’s Neurosport Program. Free downloadable cards that describe how to spot concussion and what to do if one occurs also are available on the academy’s website.
How to Evaluate Concussion
There are at least 16 different grading systems that attempt to measure severity of traumatic brain injury (TBI), the most recent about 10 years old, according to Dr. Michael A. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.
However, the AAN is developing a new grading system that "will probably be published by November of this year. That will be very useful and most updated based on class I evidence," noted Dr. Lobatz, who spoke at a meeting on primary care medicine sponsored by the Scripps Clinic.
Older grading systems do not properly prognosticate the severity of the concussion and duration of symptoms. They also fail to appreciate the sensitivity of children and adolescents to concussion, who are at higher risk than adults are for second-impact syndrome, and they are slower to recover than adults, Dr. Richard Ellenbogen, professor and chair of neurological surgery at the University of Washington, Seattle, said in an interview.
Rather than grade the level of concussion, "it’s more important to define and describe the symptoms and signs that they were suffering that were indicative of a concussion, so you can follow those," Dr. Ellenbogen said.
Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask them what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."
Sorting out preinjury vs. postinjury factors in patients with concussion is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."
Returning to Play Postinjury
Return to play is not advised if athletes are still experiencing symptoms of a concussion. If they return before they’re fully healed and suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."
Dr. Batjer emphasized that the most important elements of return to play criteria include managing the athlete’s concussion in a quiet, nonstimulating environment; being asymptomatic at rest and during exertion; clearance from the team trainer or doctor; and clearance from an independent health care provider skilled in the treatment of concussion.
To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment that provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-i84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full-contact practice, and eventual return to play.
Alternative Concussion Tests
Many other alternative tests are available, Dr. Kutcher noted, including the Axon Sports Computerized Cognitive Assessment Tool, the HeadMinder Concussion Resolution Index, and CNS Vital Signs. However, he cautioned that such tests often provide a false sense of security.
"It is the nature of neurological examination that it is not very easily put into check boxes and protocols. Doing a neurologic examination is an organic process, and so while these tools are good places to start and provide a framework for evaluation, they should never be thought of as being a complete evaluation," he explained.
The new National Football League sideline concussion assessment protocol that was announced last February draws on elements of a screening tool that was recommended in the consensus statement from the Third International Conference on Concussion in Sport, the SCAT2 (Sport Concussion Assessment Tool 2), which was modified for football. It includes a focused screening neurologic examination to exclude cervical spine and intracranial bleeding, as well as assessments of orientation, immediate and delayed recall, concentration, and balance.
The protocol is designed to "create a little more homogeneity in the way players are assessed on the field" but is not meant to "ever replace the professional judgment of a team physician or trainer on the field," said Dr. Ellenbogen, who cochairs the NFL Head, Neck, and Spine Committee with Dr. Batjer.
The Future of Concussion Treatment
Future decisions on the field of play will depend in part on the conclusions of studies designed to determine what factors increase the risk of concussion and long-term neurologic deficits in different individuals. But such studies have many methodologic challenges.
"One of the problems is people are trying to connect the dots by looking retrospectively and saying ‘You played X number of years at this position and you tell me you had this many concussions,’ and trying to use that as a definition of exposure when that is fraught with all kinds of bias and ambiguity," said Dr. Kutcher, chair of the AAN’s Sports Neurology Section. "There are efforts now at different levels to try to track players prospectively. But one of the problems there is, what are you going to track as the exposure? Right now, it is the number of concussions, but that is clearly not the whole picture. You need to be tracking the number of hits.
"If we’re ever going to make decisions on whether somebody gets to play or not based on the number of hits they’ve taken, we should have a clear scientific understanding of what those hits are doing, and we don’t," Dr. Kutcher said. "There’s a general concept that the types of hits that athletes take during contact sports can’t be good for the brain. The real question is, how bad is it? The underappreciated aspect of this is how individual that answer is. If you took 100 players and gave them the same type and number of exposures over a lifetime, you’re going to get 100 different results."
Several planned studies sponsored by the NFL, the Department of Defense, and the National Institutes of Health will evaluate new football helmet designs and test accelerometers inside them to measure the frequency and force of hits in relation to the players’ neurologic status. Other studies are proposing to compare a group of age- and position-matched former NFL players with players who played at the collegiate level and control subjects who did not play sports, according to Dr. Batjer.
In another study, Dr. Kutcher said that he and investigators from the University of North Carolina at Chapel Hill and the University of California, Los Angeles, will track the longitudinal neurologic status of players of both genders in sports with and without helmets (using accelerometer-instrumented mouth guards) throughout their career and afterward against control subjects.
Doug Brunk contributed to this report.
Greater awareness of the potential long-term sequelae from multiple concussions has prompted nearly two-thirds of states to pass legislation that is meant to protect athletes suspected of having a concussion.
These laws are spurring wider use of concussion screening tests and educational materials to inform coaches, parents, athletes, and medical professionals of the importance of identifying players suspected of having a concussion and getting them evaluated before they can return to play. Studies also are underway or being planned to determine how the risk of concussion varies among individuals and how it is influenced by the number and severity of blows to the head.
Since the enactment of the Lystedt Law in Washington in 2009, 29 other states and the District of Columbia have passed similar laws, and an additional state has a bill that at press time awaited the governor’s signature for final passage into law, according to NFL Health & Safety. In general, the laws require that athletes suspected of having a concussion be held out of games or practice until they have been evaluated and cleared to return by a trained and licensed health care provider, whose definition varies across states.
These developments are driving a change in attitude toward how concussions are evaluated and managed at all levels of sports, both in practice and on the field. "What we’re starting to see is organizations taking a look at practice parameters, [such as] limiting the amount of contact that can happen in the practice environment," said Dr. Jeffrey S. Kutcher, director of the University of Michigan’s Neurosport Program. He noted that this year the Ivy League conference became the first to limit the amount of contact that players have during practice sessions.
Return to play is now being more widely regarded as a medical decision that must be made by qualified health care providers. In a position paper last year, the American Academy of Neurology (AAN) said that return-to-play decisions should be made by a neurologist or a physician with training in the evaluation and management of sports concussion. It also called for certified athletic trainers to be present at all sporting events and practices at which athletes are at risk of concussion.
Recognizing Concussion in Youth Athletes
But while professional sports teams and universities can provide physicians or athletic trainers to screen for and diagnose concussion, youth athletes most often won’t have those resources available. They need people trained to screen for concussion and pull them out of play until they can be evaluated by a licensed health care provider.
"[High] schools are not going to have a physician on the field," Dr. H. Hunt Batjer, professor and chair of neurological surgery at Northwestern University, Chicago, said in an interview. In the metro Chicago area, "many do not have close affiliation with a trainer. Somebody is going to have to take on that role of identifying a concussed athlete. Ideally, it would not be the coach. Ideally, it would be a health professional."
To help youth and high school coaches – as well as athletes and parents – recognize the signs of concussion and know what to do to if a player gets a head injury, the AAN is offering two free, online, 20-minute safety courses created by the University of Michigan’s Neurosport Program. Free downloadable cards that describe how to spot concussion and what to do if one occurs also are available on the academy’s website.
How to Evaluate Concussion
There are at least 16 different grading systems that attempt to measure severity of traumatic brain injury (TBI), the most recent about 10 years old, according to Dr. Michael A. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.
However, the AAN is developing a new grading system that "will probably be published by November of this year. That will be very useful and most updated based on class I evidence," noted Dr. Lobatz, who spoke at a meeting on primary care medicine sponsored by the Scripps Clinic.
Older grading systems do not properly prognosticate the severity of the concussion and duration of symptoms. They also fail to appreciate the sensitivity of children and adolescents to concussion, who are at higher risk than adults are for second-impact syndrome, and they are slower to recover than adults, Dr. Richard Ellenbogen, professor and chair of neurological surgery at the University of Washington, Seattle, said in an interview.
Rather than grade the level of concussion, "it’s more important to define and describe the symptoms and signs that they were suffering that were indicative of a concussion, so you can follow those," Dr. Ellenbogen said.
Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask them what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."
Sorting out preinjury vs. postinjury factors in patients with concussion is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."
Returning to Play Postinjury
Return to play is not advised if athletes are still experiencing symptoms of a concussion. If they return before they’re fully healed and suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."
Dr. Batjer emphasized that the most important elements of return to play criteria include managing the athlete’s concussion in a quiet, nonstimulating environment; being asymptomatic at rest and during exertion; clearance from the team trainer or doctor; and clearance from an independent health care provider skilled in the treatment of concussion.
To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment that provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-i84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full-contact practice, and eventual return to play.
Alternative Concussion Tests
Many other alternative tests are available, Dr. Kutcher noted, including the Axon Sports Computerized Cognitive Assessment Tool, the HeadMinder Concussion Resolution Index, and CNS Vital Signs. However, he cautioned that such tests often provide a false sense of security.
"It is the nature of neurological examination that it is not very easily put into check boxes and protocols. Doing a neurologic examination is an organic process, and so while these tools are good places to start and provide a framework for evaluation, they should never be thought of as being a complete evaluation," he explained.
The new National Football League sideline concussion assessment protocol that was announced last February draws on elements of a screening tool that was recommended in the consensus statement from the Third International Conference on Concussion in Sport, the SCAT2 (Sport Concussion Assessment Tool 2), which was modified for football. It includes a focused screening neurologic examination to exclude cervical spine and intracranial bleeding, as well as assessments of orientation, immediate and delayed recall, concentration, and balance.
The protocol is designed to "create a little more homogeneity in the way players are assessed on the field" but is not meant to "ever replace the professional judgment of a team physician or trainer on the field," said Dr. Ellenbogen, who cochairs the NFL Head, Neck, and Spine Committee with Dr. Batjer.
The Future of Concussion Treatment
Future decisions on the field of play will depend in part on the conclusions of studies designed to determine what factors increase the risk of concussion and long-term neurologic deficits in different individuals. But such studies have many methodologic challenges.
"One of the problems is people are trying to connect the dots by looking retrospectively and saying ‘You played X number of years at this position and you tell me you had this many concussions,’ and trying to use that as a definition of exposure when that is fraught with all kinds of bias and ambiguity," said Dr. Kutcher, chair of the AAN’s Sports Neurology Section. "There are efforts now at different levels to try to track players prospectively. But one of the problems there is, what are you going to track as the exposure? Right now, it is the number of concussions, but that is clearly not the whole picture. You need to be tracking the number of hits.
"If we’re ever going to make decisions on whether somebody gets to play or not based on the number of hits they’ve taken, we should have a clear scientific understanding of what those hits are doing, and we don’t," Dr. Kutcher said. "There’s a general concept that the types of hits that athletes take during contact sports can’t be good for the brain. The real question is, how bad is it? The underappreciated aspect of this is how individual that answer is. If you took 100 players and gave them the same type and number of exposures over a lifetime, you’re going to get 100 different results."
Several planned studies sponsored by the NFL, the Department of Defense, and the National Institutes of Health will evaluate new football helmet designs and test accelerometers inside them to measure the frequency and force of hits in relation to the players’ neurologic status. Other studies are proposing to compare a group of age- and position-matched former NFL players with players who played at the collegiate level and control subjects who did not play sports, according to Dr. Batjer.
In another study, Dr. Kutcher said that he and investigators from the University of North Carolina at Chapel Hill and the University of California, Los Angeles, will track the longitudinal neurologic status of players of both genders in sports with and without helmets (using accelerometer-instrumented mouth guards) throughout their career and afterward against control subjects.
Doug Brunk contributed to this report.