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Ringing the bell on concussion management

By Peter Pollack

New guidelines reduce leeway in returning players to games after head trauma

“Concussion is a significant issue,” said Claude T. Moorman III, MD. “We’ve learned that it is a more significant issue than some of us previously thought.”

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Under the NCAA concussion management plan, a player who sustains a concussion during a game should not be allowed to return to play in that game. Courtesy of Thinkstock

Dr. Moorman, director of sports medicine at Duke University and head team physician for the Duke Blue Devils football team, recently discussed the sideline management of concussion at the 2011 annual meeting of the American Orthopaedic Society for Sports Medicine.

“Football, for example, has a culture of toughness versus safety,” he said. “But some medical conditions—including hydration and heat injury—should not be treated by allowing the athlete to push through. Concussion is similar. We need to take it seriously and not push the athlete back into the game.”

Changing the culture
When a concussion occurs, the affected brain tissue requires increased glucose (nutrients), blood flow, oxygen, and rest to recover. If the body isn’t given a chance to deliver these critical elements to the neural tissues, additional injury is possible.

“A tenuous equilibrium develops between glucose use and glucose delivery, and during this time the tissue around the area of injury remains susceptible to further injury,” said Dr. Moorman. “This ‘concussion penumbra’ is similar in some ways to the ischemic penumbra that occurs following an ischemic stroke.

“Previous severity of concussion scales weren’t all that useful. Practitioners—trainers and team physicians—had more leeway in using their personal judgment and experience to decide whether a player should be allowed to return to play. In several cases—particularly at higher levels of play—the seriousness of the injury may have been downplayed,” he continued.

A series of international symposia on concussion in sports resulted in the Zurich Guidelines, a consensus statement on concussion in sports. The most recent statement (2009) states that players should be graded on a simple yes/no scale: either the player suffered a concussion or didn’t.

“The National Collegiate Athletic Association (NCAA) has adopted a concussion management plan that’s based on the Zurich Guidelines, so if a player sustains a concussion during a game, he or she doesn’t go back,” said Dr. Moorman.

Subjective symptoms
Determining whether a player has sustained a concussion is challenging.

“Concussion has an injury pattern that’s characterized by subjective symptoms,” he said. “Orthopaedists are used to making decisions based on objective data, and it’s very difficult to get objective data on a patient who’s sustained a concussion.”

Based on the Zurich Guidelines, a staged approach should be used to determine whether a player has sustained a concussion, starting with the new Sport Concussion Assessment Tool 2 (SCAT2).

“At Duke, we use a variant we call the Pocket SCAT,” Dr. Moorman explained. “The first section includes a grading scale for various symptoms, covering things such as loss of consciousness, amnesia, headache, neck pain, blurred vision, nervousness, or anxiety.

“The second part contains a memory function test, with questions such as, ‘What venue are we at today?’ and ‘Who scored last?’

“The last part looks at balance and coordination. We’ll have a player stand heel-to-toe, hands on hips with eyes closed, and maintain stability for 20 seconds. We count the number of errors—such as opening the eyes or moving out of position—that the player makes. If a player makes five or more errors in 20 seconds, he or she probably has a concussion.”

A sideline physician who suspects that the player has a concussion generally goes through the whole Pocket SCAT. “The cumulative score is important, but is subject to interpretation of the sideline physician, who may do additional evaluation to determine severity,” explained Dr. Moorman.

Each Duke player, for example, undergoes ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) neurocognitive testing before the season begins. This establishes a baseline that can be compared to the player’s responses after injury.

“Beyond that, if the patient isn’t clearing, we might consider further testing, such as a computed tomography scan of the head and possible referral to a neurologist,” Dr. Moorman said.

On the side of safety
According to Dr. Moorman, team physicians working with professional athletes may have a little more “wiggle room” in allowing players to return to the game.

“The Zurich Guidelines are not definitive on the standard for high-level professional athletes,” he said. “The National Football League (NFL) wants pro football players to be treated the same way that NCAA athletes are, but the rules may not be as clear-cut in other pro sports. I anticipate that eventually the guidelines will cover all athletes.

“In terms of protecting our young athletes, if a player has a concussion during a game, I wouldn’t send him back that day. A physician who isn’t comfortable in being the definitive evaluator and providing the necessary follow-up should develop a network of primary care sports doctors and pediatric neurologists with more experience in managing such injuries.

“Concussion,” he said, “is different from other injuries. The stakes are much higher, and team physicians have to get it right. Unfortunately, a lot of uncertainty exists about the objective nature of these injuries, which makes treating them much more challenging. Until we better understand the objective nature of the injury, we have to err on the side of safety.”

Disclosure information: Dr. Moorman—Smith & Nephew, HealthSport, Histogenics, Oxford Press, Elsevier, Sage Publications, SJOA/Datatrace.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Additional Resources:
The SCAT2 form
(PDF)
The Zurich Consensus

The importance of a concussion baseline
Research presented at the 2011 annual meeting of the AOSSM underscored the importance of having athletes take the SCAT2 test prior to the start of a playing season. According to presenting researcher, Anikar Chhabra, MD, of The Orthopaedic Clinic Association in Phoenix, Ariz., “Our results showed that otherwise healthy adolescent athletes do display some variability in results, so establishing each player’s own baseline before the seasons starts and then comparing those results to test results following a concussion leads to more accurate diagnosis and treatment.”

Dr. Chhabra’s study involved 1,134 athletes (872 males, 262 females; average age, 15 years old) who participated in interscholastic athletic teams at 15 different high schools in the Phoenix area. Each participant answered a brief questionnaire on concussion history and took the SCAT2 test.

At baseline, female athletes scored significantly higher on the SCAT2 total score compared to male athletes; athletes with a prior history of concussion scored significantly lower than athletes who had never sustained a concussion.

“The data show how the SCAT2 scores can be used and interpreted as a sideline concussion tool and as an initial baseline analysis. With concussions accounting for approximately 9 percent of all high school athletic injuries, accurately using assessments like SCAT2 to quickly determine an athlete’s return to play probability is critical to long-term athletic and educational performance,” said Dr. Chhabra.

Bottom Line

  • New guidelines state that any player who sustains a concussion should be removed from play.
  • Sideline diagnosis of concussion is conducted using a multistage SCAT2 test to gauge impairment in areas such as memory, cognition, balance, and coordination.
  • Orthopaedists serving as team physicians for sports that result in concussions (football, soccer, hockey) may wish to engage with a network of peers who have experience in diagnosing and treating neurologic trauma.

AAOS Now
September 2011 Issue
http://www.aaos.org/news/aaosnow/sep11/cover1.asp