Often the first explanation / opinion a patient and family hear is the one that resonates the loudest and longest within their minds. This is why it is crucial that we give honest and well-informed perspectives. Recently, Dr. Elizabeth Weinstein (a beloved friend from Indiana University) came to Carolinas and provided us with this critical information regarding concussions. Not only do we need to know how to diagnosis concussion, but often what families are most interested in is “when can our star athlete return to play?”

Concussion has no universally agreed upon definition or classification.

• There used to be “Grades” 1-3, but no longer.
• There are neurocognitive testing that can objectively measure severity, but in the ED it is merely a matter of do you believe the patient has a concussion – Yes or No?
• Symptoms can vary widely between individuals and with severity.
  • Acutely often have some form of (1) loss of postural stability and/or (2) loss of cognitive function.
  • Symptoms can range from “just not feeling right” all the way to LOC with persistent vomiting.

BONUS MORSEL: Dr. Weinstein mentioned that “AAOx3” is not a sensitive test for cognitive dysfunction. Ask the patient about specifics pertaining to the game (what play were they running, what quarter was it, etc) and about specifics from the day’s events (what classes were attended in school today, what was for lunch, etc).

Return to play guidelines are a graduated approach

I think that understanding this is important… I tell patients and families this explicitly as I want to make sure that they have heard it correctly from the beginning. I hope that they will hear it again when they see the primary MD and/or specialist.

• No same game, same day return of play after a concussion.
• Player must get medical evaluation prior to return to play (that is where we come in).
• After a concussion is diagnosed, everyone starts at Rehabilitation Stage 1 and then progresses through to Stage 6.
  • The patient may progress to the next Stage once able to achieve that Stage’s goal without having symptoms.
  • The duration that an individual remains at a Stage is dependent upon his/her symptoms and ability to recover.
  • It is tailored for each individual.
    • Many will progress through a single Stage in ~24 hours and achieve a full recovery by the end of a week; however, it may take a week or more to progress between stages.
    • This is also why it is imperative that they have a medical professional supervising the recovery process.

Stage 1: Complete Physical AND Cognitive rest (no algebra, no video games, etc)
Stage 2: Light aerobic exercise (walking, stationary bike, etc) in order to increase Heart Rate.
Stage 3: Sport-specific exercise (Skating, running) in order to add movement.
Stage 4: Non-contact training drills (passing drills) and resistance training. Increases cognitive load and coordination.
Stage 5: Full contact practice after medical clearance. Assessing functional skills.
Stage 6: Normal game play.

The Potential Consequences

Stress these to get your patient and family to understand the ramifications of trying to play in the championship tournament that weekend.

• Recurrent concussions – having one makes it more likely (~5 times) that you’ll have another
• Postconcussive syndrome – ~25% of concussed individuals
• Chronic Traumatic Encephalopathy – think about Rocky Balboa
• Second Impact Syndrome – Rare but real. Re-injury during a vulnerable period. No way to predict it. Results in massive cerebral blood flow dysregulation and edema and herniation.

McCory P, et al. Consensus statement of concussion in sport – The 3rd International Conference on Concussion in Sport, hel in Zurich, November 2008. Journal of Clinical Neuroscience; 16, 2009: pp. 755-763.

Link to CDC’s “Heads Up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI).