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.
Dr. Michael A. Lobatz
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.