ficulties may evolve with increased metabolic demands. International consensus recommendations have suggested a graduated exertional protocol. Such a protocol may involve the athlete successfully moving through the following exertional stages: (1) light aerobic exercise (walking, stationary biking), (2) sportspecific training (ice skating in hockey, running in soccer- typically moderately exertional), and (3) non-contact training drills (heavily exertional, including heavy weight training, sprints, all positional maneuvers, etc). If the athlete’s previously resolved post-concussion symptoms return at any point during the graded return to physical exertion, the athlete should return to the previous exertion level at which they were last asymptomatic. In addition to physical exertion, cognitive exertion should be closely monitored along with its overall relationship to symptoms. It should be noted that physical and cognitive exertion may have different effects on symptoms and resolution of difficulties under both conditions should be met (especially in student athletes). Clearly, considerations according to prior history of concussion and outcome from previous concussion, as well as any suspected deception in the athlete’s symptom reporting may influence return to participation and management directives. 3. Intact Neurocognitive Functioning
Post-injury assessment in the form of neurocognitive testing should also be considered to help determine overall management and return-to-participation issues. Cognitive recovery is considered achieved when the athlete’s performance either returns to baseline levels or, in the absence of baseline, is consistent with premorbid estimates of functioning when the test data are compared to normative values (clinicians should utilize test batteries that have readily available athlete-specific norms). As described above, a pre-season or baseline neuropsychological assessment would be a helpful tool against which to compare post-injury functioning to “normal” functioning for the injured athlete. Many practitioners prefer to complete acute and serial follow-up evaluations in order to gain insight into the extent and type of cognitive impairment created by the injury. Such data can help with prognosis (Iverson et al., 2007), help to determine when the athlete may return to exertion, and may also help to provide academic recommendations and accommodations. Once the athlete has been cleared medically, is symptom free at rest and with physical exertion, and within expected levels on cognitive testing, he/she may return to full-contact training, and then to competition. Such evidence-based parameters are becoming the “gold standard” for return to sport participation following concussion and are becoming widely implemented at all levels of sports participation. Summary
The field of sports concussion management has evolved rapidly over the past several years. There has been more data published regarding this injury in the past 10 years, than the previous 100 combined. Management has seemingly evolved to much more individually-driven management protocols that have been formulated through scientific evidence and the labors of many researchers across the world. The days of generally grading a concussion at the time of injury, and then having the athlete sit out a week, or perhaps two (or even perhaps going into the same game), is being replaced with safer and more prudent evidence-based management parameters. Relatedly, data is now available to better understand the phenomenology of sports concussion, risk factors, typical outcomes, effects of repetitive
injury, subtypes of concussive injury, and even treatment and rehabilitation protocols. In short, we as a field have learned a tremendous amount over the past several years and, yes, we are in the midst of a “paradigm shift” for managing and treating this injury. Notably, however, research on paradigm shifts have elucidated that it takes, on average, 17 years for shifts to occur from the inception of the idea to true standard medical practice. As if not challenging enough to provide evidence-based management protocols, we as a field also bear the responsibility of educating parents, coaches, athletes, and, perhaps most important, clinicians regarding these management advances. It is an exciting time to be involved in the “subspecialty” of sports concussion management, though much more work needs to be done. About the Author
Michael Collins, PhD, a nationally renowned sports concussion clinician and researcher, joined the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program as assistant director when the program was established in September 2000. The program encompasses an ongoing clinical service and research team whose focus is providing the best possible evaluation and management of sports-related concussions in athletes of all levels. Referencess Langlois JA, Rutland-Brown W, and Wald M. The epidemiology and impact of traumatic brain injury: a brief overview. Journal of Head Trauma Rehabilitation. 21(5): 375-8, 2006. Congress of Neurological Surgeons. Committee on Head Injury Nomenclature: Glossary of Head Injury. Clinical Neurosurgery. 12:386–94, 1966. Quality Standards Subcommittee, American Academy of Neurology. Practice parameter: the management of concussion in sports. Neurology. 48:581-5, 1997. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the first International Conference on in Sport, Vienna 2001. Clinical Journal of Sports Medicine. 12(1):6-11, 2002. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the second International Conference on Concussion in Sport, Prague 2004. British Journal of Sports Medicine. 39:196-204, 2005. Giza CC and Hovda DA: The neurometabolic cascade of concussion. Journal of Athletic Training. 36:228–235, 2001 McAllister TW, Sparling MB, Flashman LA, et al. New developments in management of sports concussion: Neuroimaging Findings in Mild Traumatic Brain Injury. Journal of Experimental and Clinical Neuropsychology. 23(6):775-791, 2001. Cantu RC and Voy R. Second impact syndrome: a risk in any contact sport. Physician and Medicine. 23:27-34, 1995. Collins MW, Iverson GL, Lovell MR, et al. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Journal of Sports Medicine. 13:222-229, 2003. Iverson GL, Gaetz M, Lovell MR, et al. Relation between subjective fogginess and neuropsychological testing following concussion. Journal of the International Neuropsychological Society. 10(6): 904-906, 2004. Concussion in Sport Group: Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clinical Journal of Sport Medicine. 12:6-11, 2002. Schatz, P, Pardini, JE, Lovell MR, et al. Sensitivity and Specificity of the ImPACT Test Battery for Concussion in Athletes. Archives of Clinical Neuropsychology. 21, 91-99, 2006. van Kampen D, Lovell MR, Collins MW, et al. The “Value Added” of neurocognitive testing in managing sports concussion. American Journal of Sports Medicine. 34 (10), 1630-1635, 2006. Fazio V, Lovell MR, Pardini J, et al. The relationship between post-concussion symptoms and neurocognitive performance in concussed athletes. Neurorehabilitation (special issue). In press. Collins MW, Lovell MR, and McKeag DB. Current issues in Managing Sports-Related Concussion. Journal of the American Medical Association. 282(24), 2283-2285, 1999. Guskiewicz KM, McCrea M, Marshall SW, et al.: Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA concussion study. Journal of the American Medical Association, In Press. Collins MW, Lovell MR, Iverson G, et al. Cumulative effects of concussion in high school athletes. Neurosurgery. 51:1175-1181, 2002. Field M, Collins MW, Lovell MR, et al. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. Journal of Pediatrics. 142(5), 546-553, 2003. Mihalik J, Stump J, Collins MW, et al. Posttraumatic migraine characteristics in athletes following sports-related concussion. Journal of Neurosurgery. 102:850-855, 2005. Majerske CW, Milhalik JP, Dianxu R, et al. Concussion in sports: The effect of post-concussive activity levels on symptoms and neurocognitive performance. Journal of Athletic Training. In Press. Iverson G. Predicting slow recovery from sports-related concussion: the new simple-Complex distinction. Clinical Journal of Sport Medicine. 1731-37, 2007. BRAIN INJURY PROFESSIONAL
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