The impact of the TBI varies depending on the severity of initial injury; the rate or completeness of physiological recovery; the functions affected; the meaning of dysfunction to the individual; and the resources available to aid recovery. "We try to strengthen what is weak with repetitive activities," Dr. Lobatz said. "When we realize that we cannot strengthen what is weak – that there are permanent deficits – we teach people to adapt. That is what rehabilitation is all about: Strengthen what is possible to be strengthened and adapt to what cannot be strengthened."
In athletes who are still experiencing symptoms of a concussion, return to play is not advised. If they return before they’re fully healed and then 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."
To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment which 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:i76-84). 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.
Early on, "you may want to pull the student out of school for a week or two, for physical rest and mental rest," Dr. Lobatz said.
He also recommended the Acute Concussion Evaluation–Physician/Clinician Office Version, a checklist that "helps you identify red flags, make a diagnosis, look at risk factors for protracted recovery," he said. It can be downloaded free of charge from the U.S. Centers for Disease Control and Prevention website.
Dr. Lobatz said that he had no relevant financial disclosures to make.