Use of the stepwise progression return-to-play protocol following concussion among practicing athletic trainers

Age-Group Differences and Annual Variation in Return-To-Play Practices After Sport-Related Concussion

OBJECTIVE

To examine return-to-play (RTP) practice differences between high school and collegiate athletes, as well as the stability (ie, year-by-year) in these practices over a 5-year period. We hypothesized that similar protocols for treatment will be comparable across competition levels and that these practices will vary year-to-year.

DESIGN

Prospective cohort study.

SETTING

Nine high schools and 4 National Collegiate Athletic Association Division III colleges in Southeastern Wisconsin.

PARTICIPANTS AND INDEPENDENT VARIABLES

Two-hundred seventy-three (N = 273) athletes with sport-related concussions (SRCs). Independent predictors included competition level (high school, n = 88 vs collegiate, n = 185) and year-of-injury.

OUTCOME MEASURES

Athletes were evaluated prospectively for differences in symptom duration, symptom free waiting period (SFWP), and time to RTP, as well as longitudinal changes in management.

RESULTS

High school and collegiate athletes experienced comparable median symptom duration (high school, 6.0 days, interquartile range (IQR) = 3.5-11.0; college, 6.0 days, IQR = 4.0-9.0, P = 0.95), SFWP (high school, 5.0 days, IQR = 3.0-8.0; college, 5.0 days, IQR = 3.0-7.0, P = 0.12), and total time to RTP (high school, 10.5 days, IQR = 7.0-16.0; college, 11.0 days, IQR = 8.0-14.0 days, P = 0.94). A Cox regression analysis revealed a nonsignificant trend toward longer SFWPs in high school athletes (P = 0.055; hazard ratio = 1.347, confidence interval = 0.99-1.83). Among football players, SFWPs in 2017 (Median = 3.5 days, IQR = 1.5-5.0 days) were significantly longer than those in 2014 (Median = 5.0 days, IQR = 4.0-8.5 days, P = 0.029) after correction for multiple comparisons.

CONCLUSION

Similar postinjury and RTP management practices were observed at the high school and collegiate levels after SRCs. Symptom duration and time from injury to unrestricted RTP were comparable, although high school athletes may have longer SFWPs.

Time to Authorized Clearance from Sport-Related Concussion: The Influence of Healthcare Provider and Medical Facility

CONTEXT

Return-to-play following sport-related concussion(SRC) requires authorized clearance from a healthcare provider(HCP). Variability in HCPs and facilities where athletes seek care may influence return time.

OBJECTIVE

Determine the initial examiner, HCPs that authorize clearance, and medical facilities authorizing clearance among high school student-athletes following SRC, and compare authorized clearance time by HCPs and medical facilities.

DESIGN

Prospective Cohort Study.

SETTING

High school.

PATIENTS OR OTHER PARTICIPANTS

Student-athletes(n=16,001) with SRC participating in STATE-XXX High School Athletic Association(XHSAA)-sponsored athletics.

MAIN OUTCOME MEASURE(S)

Frequencies of initial examiner and authorized clearance for each HCP(Doctor of Osteopathic Medicine(DO), Doctor of Medicine(MD), Nurse Practitioner(NP), Physician Assistant(PA)) and medical facility (Neurologist's Office, Team Physician, Primary Care Physician or Pediatrician's Office(PCP), Hospital, Urgent/Ready Care) for each SRC case. Kaplan-Meier curves and Peto tests evaluated differences in median time to authorized clearance between HCPs and facilities. Only cases with a follow-up authorized clearance date(80.3%, n=12,856) were included in authorized clearance and time to return analyses.

RESULTS

An athletic trainer was at least one of the initial examiners for 71.3%(n=11,404) of cases; 80.2%(n=12,990) had only one initial examiner. There was an association between initial examiner and medical facility providing clearance for athletic director(χ2=52.6, p≤.001, V=.06), athletic trainer(χ2=172.0, p≤.001, V=.12), coach(χ2=161.5, p≤.001, V=.11), DO(χ2=59.4, p≤.001, V= 07), and NP(χ2=10.0, p .03, V=.12). The majority(n=8,218, 63.9%) received clearance by an MD; 70.8%(n=9,099) were cleared at a PCP. Median time to authorized clearance varied by facility(Urgent/Ready Care: 7 days[4,11], Hospital: 9 days[6,14], PCP: 10 days[6,14], Team Physician: 12 days[8,16], Neurologist Office: 13 days[9,20]; p ≤ .001).

CONCLUSIONS

Clearance was frequently provided by an MD and at a PCP. Median time to return to unrestricted participation following SRC varied by HCP and medical facility. Future research should elucidate why differences exist and determine why athletes seek care at different medical facilities.

Concussion-Recovery Trajectories Among Tactical Athletes: Results From the CARE Consortium

CONTEXT

Assessments of the duration of concussion recovery have primarily been limited to sport-related concussions and male contact sports. Furthermore, whereas durations of symptoms and return-to-activity (RTA) protocols encompass total recovery, the trajectory of each duration has not been examined separately.

OBJECTIVE

To identify individual (eg, demographics, medical history), initial concussion injury (eg, symptoms), and external (eg, site) factors associated with symptom duration and RTA-protocol duration after concussion.

DESIGN

Cohort study.

SETTING

Three US military service academies.

PATIENTS OR OTHER PARTICIPANTS

A total of 10 604 cadets at participating US military service academies enrolled in the study and completed a baseline evaluation and up to 5 postinjury evaluations. A total of 726 cadets (451 men, 275 women) sustained concussions during the study period.

MAIN OUTCOME MEASURE(S)

Number of days from injury (1) until the participant became asymptomatic and (2) to complete the RTA protocol.

RESULTS

Varsity athlete cadets took less time than nonvarsity cadets to become asymptomatic (hazard ratio [HR] = 1.75, 95% confidence interval = 1.38, 2.23). Cadets who reported less symptom severity on the Sport Concussion Assessment Tool, third edition (SCAT3), within 48 hours of concussion had 1.45 to 3.77 times shorter symptom-recovery durations than those with more symptom severity. Similar to symptom duration, varsity status was associated with a shorter RTA-protocol duration (HR = 1.74, 95% confidence interval = 1.34, 2.25), and less symptom severity on the SCAT3 was associated with a shorter RTA-protocol duration (HR range = 1.31 to 1.47). The academy that the cadet attended was associated with the RTA-protocol duration (P < .05).

CONCLUSIONS

The initial total number of symptoms reported and varsity athlete status were strongly associated with symptom and RTA-protocol durations. These findings suggested that external (varsity status and academy) and injury (symptom burden) factors influenced the time until RTA.

Concussion in Sports

Concussion, a peculiar type of mild traumatic brain injury (mTBI), is an injury frequently encountered in various contact and noncontact sports, such as boxing, martial arts, American football, rugby, soccer, ice hockey, horse riding, and alpine skiing. Concussion occurs anytime external forces of specific intensities provoke acceleration-deceleration of the brain, and it is characterized by the rapid onset of short-lived impairment of neurologic functions, spontaneously resolving within weeks, persisting for longer times only in a small percentage of cases. A wide range of molecular alterations, including mitochondrial dysfunction, energy deficit, and gene and protein expression changes, is triggered by concussion and lasts longer than clinical symptoms. In recent years, concussion has become a primary issue of discussion among sports medicine professionals, athletes, media, and sports sponsors in relation to athletes' return to play, after a concussion. Continued improvement in prevention and management of concussed athletes requires extensive research from different disciplines. Research work needs to focus on both prevention and management. Researchers and clinicians' efforts should be dedicated to a better understanding of the molecular changes occurring in the post-concussed brain and to clearly define healing after concussion for a safe return of athletes to play. It is essential for sports medicine professionals to stay informed about the advances in understanding concussions and how to rehabilitate each single player who sustained a concussion.

Functional Head Impulse Test in Professional Athletes: Sport-Specific Normative Values and Implication for Sport-Related Concussion

Dizziness, slow visual tracking, or blurred vision following active head (or body) movements are among the most common symptoms reported following sport-related concussion, often related to concurrent dysfunctions of the vestibular system. In some cases, symptoms persist even if bedside and auxiliary standard vestibular tests are unremarkable. New functional tests have been developed in recent years to objectify neurological alterations that are not captured by standard tests. The functional head impulse test (fHIT) requires the patient to recognize an optotype that is briefly flashed during head rotations with various angular accelerations (2,001–6,000 deg/s²) and assesses the proportion if correct answers (pca). 268 active professional athletes (23.70 ± 5.32y) from six different sports were tested using fHIT. Pca were analyzed both pooling head acceleration in the range of 2,001–6,000 deg/s² and computing a single pca value for each 1,000 deg/s² bin in the range 2,001–8,000 deg/s². No significant difference (p = 0.159) was found between responses to head impulses in the plane of horizontal (pca: 0.977) and vertical semicircular canals (pca: 0.97). The sport practiced had a major effect on the outcome of the fHIT. Handball players achieved a better performance (p < 0.001) than the whole athlete group, irrespective of the direction of head impulses. The pca achieved by athletes practicing snowboard, bob and skeleton were instead significantly below those of the whole athlete group (p < 0.001) but only when vertical head impulses were tested. Overall, pca declined with increasing head acceleration. The decline was particularly evident in the range not included in the standard fHIT exam, i.e., 6,001–8,000 deg/s² for horizontal and 5,001–8,000 deg/s² for vertical head impulses. When vertical head impulses were tested, athletes practicing snowboard, bob and skeleton (non-ball sports) showed, beside the lower overall pca, also a steeper decline as a function of vertical head acceleration. The findings suggest that: (1) functional VOR testing can help understanding sport-specific VOR requirements; (2) the fHIT is able to detect and objectify subtle, sport-specific changes of functional VOR performance; (3) if sport-specific normative values are used, the fHIT test procedure needs to be optimized, starting from the highest acceleration to minimize the number of head impulses.