General injury Management:
- There is no one-size-fits-all approach to concussion management.
- Patients do not need to be kept in a dark room, give up electronics, cease all physical activity and give up their social lives.
- Telling patients that their brain is bruised is an easy explanation, but it does not help them understand how and why certain activities make them feel worse (or better). Do explain the concept of the metabolic injury” in order to facilitate appropriate self-management, using developmentally appropriate language.
- Assess patients’ understanding of the injury to determine how they will manage their preferred or expected activities, and to see if they understand how certain choices will facilitate or impede their own recovery
- Unlike other injuries and illnesses where athletes tend to push through pain and symptoms until they become intolerable, concussions must be managed differently. Patients need to know that the goal is to stop activities or take breaks before symptoms worsen or recur. They need to be told explicitly how to manage this injury differently from other illnesses and injuries.
- Advise caution for driving while symptomatic, and particularly when rapid head or eye movements trigger symptoms and reaction time is below-average.
- Athletes and parents must understand that any symptoms that cannot be explained by other factors, combined with a hard bump or blow, can indicate a concussion, even when symptoms seem to resolve fairly quickly.
- When patients are symptomatic, individualized academic supports and adjustments will be needed, based on their symptoms and their unique academic setting and history. Reduced school days alone, or abstaining from all testing, can be counter-productive.
- There is no magic number of symptoms or days of mandated rest that indicate readiness to return to school, with updated Berlin Guidelines recommending return to school within a couple of days.
- Partial days (other than missing PE or some specials) should not be managed if symptom management is sufficiently managed and individualized.
- When sending students back to school, they will often need individualized supports and accommodations. The CDC’s Tips for Classroom Teachers lists many examples of appropriate school-based accommodations.
- 504 plans are not necessary for most students, particularly within first few weeks.
- Neurocognitive testing is the cornerstone of concussion management, when interpreted by neuropsychologists, but it is only one tool and should never be the sole basis for diagnostic or management determinations. Interpret baseline testing with great caution.
- Computer-based neurocognitive tools developed for concussion management (e.g., ImPACT, CNS Vital Signs and Axon) should be used judiciously post-injury. They should not be used automatically or routinely, since the testing itself can lead to a worsening of symptoms, and should only be interpreted by neuropsychological testing experts—a weekend class or CME is not sufficient.
- There is no such thing as a passing score on ImPACT or any other computerized neurocognitive test on the market.
- Baseline testing has become widespread since it can be administered by individuals with minimal training in standardized neurocognitive testing, yet it frequently yields unreliable scores due to testing conditions. Updated international consensus guidelines do not recommend widespread wholesale baseline testing for most children and adolescents.
- Home-based testing may be approved by the for-profit test manufacturers, but it is clinically contraindicated.
- Tests developed for adults may not be measuring the same skills in children, even if recommended by test manufacturers.
- Multi-hour test batteries are not needed for appropriate post-injury management.
- SCAT5/ChildSCAT5 are not recommended for routine office evaluation and monitoring post-injury.
Return to Play:
- As per Georgia Law and most concurrent professional practice standards, there is no same day return to sports for children and adolescents when a concussion is suspected.
- Athletes and parents need to understand the medical risk of continuing to play sports with concussive symptoms, as well as the impact that this will have on the quality of their play. Parents, too, should be informed of the risks of Second Impact Syndrome” and that although it is rare, it seems to occur only in adolescents.
- Individuals should not return to organized or team sports, or any sports with risk of contact, without explicit, written, medical clearance.
- Clearance should be based on:
- Return to baseline symptom levels without medications prescribed for symptom management post-injury
- Return to full academic load (even if still making up missed work)
- Return to pre-injury cognitive functioning
- Completion of supervised, stepwise, progressive return-to-play / return-to-activity protocol that includes increasingly lengthy and strenuous cardiovascular activity, in addition to exercises involving rapid positional changes in order to best ensure complete resolution of any vestibular symptomsNote, too, that prolonged absence from sport can lead to deconditioning, which also places athletes at risk of increased injury. Just because an athlete has been medically cleared from their concussion, it does not always mean that they are otherwise ready for return to unrestricted competitive play.
Prolonged Recoveries, Referrals, Post-Concussion Syndrome, and Risks:
- When recovery is prolonged, it is most often due to the combined impact of pre-injury factors that exacerbated, and were exacerbated by, the impact of the concussion. In some cases – particularly with persistent migraine and anxiety – additional supports will be necessary in order for the individual to recover to pre-injury levels and for all symptoms to fully resolve.
- Referral to a certified vestibular therapist is recommended when dizziness and symptoms triggered by oculomotor and vestibular testing persist beyond a couple of weeks.
- Chronic post-concussive symptoms are more often associated with poor injury management or other factors that pre-dated the injury, or that were worsened by injury and not appropriately or fully resolved, than signs of permanent brain injury (AKA Post-Concussion Syndrome). These factors include, for example, persistent migraine, cervicogenic headache, vestibular/oculomotor impairment, anxiety, and/or sleep disruption, in addition to poor post-injury management or patient compliance.
- There is no magic number of concussions that is too many. “Three-strikes-and-your-out” rules are not based on brain science. Decisions to retire from sport are highly individualized, based on a number of factors including but not limited to number of injuries, length of recovery periods, and apparent sensitivity to blows to the head.
- There are many benefits to team sports with higher rates of contact and injury, and there is much that can be done to minimize concussion risk. Long-term effects of injury are least likely when recovery is 100% complete before returning to play.
- CTE is highly controversial. It cannot be diagnosed prior to time of death.
Handouts for related healthcare providers, including documents for in-office assessment, can be found on the Concussions Resources page of my website.
I am also available to provide consultation to related healthcare providers, schools, teams, and recreation agencies on an as-needed or contractual basis.