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Monday, July 2, 2012

Return to Play Guidelines after a Concussion

Okay, so we have managed the concussion and we are to the point where the athlete has been cleared to participate- but we don't jump in head first - we now follow a progressive return to play. This is for the safety of the athlete, trust us! Remember, as I keep saying, what was done 10 or 20 years ago is very different now.

 Why? Because research has told us that activity can bring symtoms back in the case of a concussion and return to full participating with underlying concussion symtoms can result in Second Impact Syndrome which if you go back to our definitions blog- you know that Second Impact Syndrome occurs when an athlete sustains a head injury before the concussion is healed. This does not have to be a major blow, it could be a minor contact to the body that causes the brain to hit the skull and can cause Second Impact Syndrome. This is very serious and is often life threatening and/or fatal.

Generally each step of the progressive return to play is approximately 24 hours. This includes the activity and adequate time to rest and recover prior to the next step. Communication as to whether the athlete is feeling any symptoms and the administrator watches for any signs of a concussion is important. It is also important that the evaluator watch the athletes ability to perform. If at any time the athlete becomes symptomatic during a test, they must drop back to the last step that was asymptomatic. Each step becomes progressively more difficult, the last couple being sport specific, the last being full exertional testing. Cardio vascular exercise, strength training, balance, dynamic movement, plyometrics, sport specific skills can and will often be incorporated at the appropriate time during the progressive return to play protocol.

Please remember- no concussions are alike. Each one is unique to the individual and all cases are handled on a case by case basis.







ImPACT Testing: What is this test all about?

Concussion research has evolved so much over the years- we all know this. It is a widely discussed topic these days- even when we are watching our favorite professional sports teams.

ImPACT testing is a neurocognitive test that was developed in the early 1990's by two doctors whom felt a neurocognitive test was needed to evaluate the signs and symptoms, visual memory, processing speed and reaction time. It is an objective test and to the best of its ability, we can use the data to determine the effects the concussion is having on each individual. It is important to understand that this is not the only "tool" that is to be used in making decision regarding a players participation status. For example if an athlete "passes" ImPACT and is still suffering from symptoms of a concussion, we may not return them to play. (resource: ImPACT website)

The test is made up of 5 sections (taken from ImPACT website)
  1. Demographics/Health Questionnaire
  2. Current symptom and conditions inventory
  3. Neuropsychological testing (6 modules in this section)
  4. Injury Description
  5. Test scores (only administrator can see this after testing)
* we often do another symptom/condition inventory at the end of the test to determine if the testing caused any increase or addition of concussion symptoms/conditions. This is an option we often chose- it is not mandatory for the test.

This "meat" of the test is section 3 where 6 modules are administered. (taken from ImPACT website)
Modules:
  1. Word discrimination: assesses attentional processes and verbal recognition memory
  2. Design Memory: assesses attentional processes and visual recognition memory
  3. X's and O's: assesses visual working memory and visual processing speed
  4. Symbol Matching: assesses visual processing speed, learning and memory
  5. Color Matching: assesses reaction time, impulse control, and response inhibition
  6. Three Letter Memory: assesses working memory and visual-motor response speed
I suggest taking a demo test yourself to get a better understanding- you will be amazed what the test actually is and what your athletes or even your own child is experiencing when taking this test.
http://www.impacttestonline.com/impacttestdemo/

Now many ask can athlete "throw the test off" or "sandbag" the test- goal being if they score really poorly on the baseline- if they were to sustain a concussion, when they take the test again they would not appear to do so badly and we may not think they actually have a concussion. Another thought is that we often hear- "they probably couldn't pass even if they weren't concussed". ImPACT test red flags and has a built in validity index that would signal to the administrators potential problems. All baseline invalid tests must be re-tested.

The medical world has been working very hard at concussion testing, education, prevention, etc. What we all have to keep in mind is that when put in a situation, an athlete will often want to put the game before their long term health. We know through research that there are long term effects such as early onset of dementia, Alzheimers disease, and depression to name a few. In order to protect our athletes- each and every member of the athletics team needs to educate themselves on the current research.

Here are some useful resources:
http://impacttest.com/concussion/overview
http://impacttest.com/concussion/primary_prevention
http://impacttest.com/concussion/diagnosis
http://www.sportsconcussions.org/ibaseline/
http://www.cdc.gov/concussion/sports/
http://www.ncaa.org/wps/wcm/connect/public/NCAA/Health+and+Safety/Concussion+homepage/