Faster recovery from concussion following immediate removal from play

Getting off the field is key to getting athletes back in the game

A recent study out of the University of Florida confirmed the importance of immediately removing athletes from play after they have suffered a sports-related concussion.

Shorter symptoms and quicker return to play

The study, which looked at more than 500 athletes across 18 different sports, showed that immediate removal from sport not only reduced the number of days that the athlete experienced symptoms but it also resulted in quicker return to play. According to the report, student-athletes immediately removed from activity experienced symptoms for two days less— and were able to return to play three days earlier— than their peers who experienced a delayed removal from activities.  The data also suggests that immediate removal may lessen the severity of acute symptoms.[i]

These findings echo previous research, adding weight to current management practices that require athletes suspected of having a concussion be immediately removed from play.[ii] For those working with adolescents, immediate removal from play may be even more important—one study showed that adolescents immediately removed from activity returned to play 22 days earlier than their peers who were not.[iii]

The right rest

Multiple studies show that immediate rest is key, but this study suggests that too much rest may not be the best approach. While there is a consensus that 24-48 hours of rest immediately after sustaining a concussion is crucial to a speedy recovery, prolonged rest may increase the risk of an extended recovery. [iv] Instead, properly timed physical activity could improve outcomes. [v] Researchers believe physical activity may encourage better outcomes by increasing the brain’s uptake of proteins associated with healing and neural repair and could speed up a return to homeostasis.[vi]

Catch it when you can

Despite the strong evidence that immediate removal is essential, as many as 50% of athletes are delayed in being removed from sport after sustaining a concussion.[vii] It’s unlikely that all of these delays are simply caused by a failure to report or non-compliance with concussion guidelines. In this study, a high proportion of those who were not immediately removed from sport were people who experienced delayed symptom onset— helping to explain why so many athletes continue to play after the impact responsible for the concussion.

Unfortunately, not every concussion is immediately detectable. Still, as soon as symptoms are noticed, it is time to get off the field immediately. Mounting data shows that removal from play at the time of symptom onset— even if that is after the impact that caused the concussion— gives the best chance of avoiding a prolonged recovery. [viii]

Further to go

There have been great strides in the recognition and reporting of sports-related industries over the last two decades, but there is still a long way to go. Too many athletes are still not immediately removed from play.

This study, like several before it, highlights the importance of educating athletes, coaches, and trainers on how to identify symptoms and the importance of immediate removal from play—it’s what is best for recovery, and the fastest way to get athletes back in the game.

 

 

References

[i] Asken, B. M., Bauer, R. M., Guskiewicz, K. M., McCrea, M. A., Schmidt, J. D., Giza, C. C., ... & Broglio, S. P. (2018). Immediate removal from activity after sport-related concussion is associated with shorter clinical recovery and less severe symptoms in collegiate student-athletes. The American journal of sports medicine46(6), 1465-1474.

[ii] Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM. “Playing through it”: delayed reporting and removal from athletic activity after concussion predicts prolonged recovery.  J Athi Train. 20016; 51(4):329-335.

[iii] Elbin R. Sufrinko A, Schatz, et al. Removal from play after concussion and recovery time. Pediatrics. 2016; 183(3):e20160910

[iv]  McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th International Conference on Concussion in Sport held in Berlin, October 2016 [published online April 26, 2017]. Br J Sports Med. Doi: 10, 1136/bjsports-2017-097699

[v] Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?” Recommendations for activity resumption following concussion in athletes, civilians, and military service members.  J Head Trauma Rehabil. 2013 28(4) 250-259

[vi] Griesbach GS, Hovda D, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function, Neuroscience. 2005; 125(1):129-139.

[vii] Asken (2016).

[viii] Asken (2018).


Managing Assessment Variances Within Sports Medicine Teams

Athletic Therapists (ATs) are commonly the first medical providers or health care professionals available onsite to evaluate any injuries that may occur during a competition or practice. They are not only crucial during competition, but also post competition during the injury management and return-to-play decision-making process. Athletic Therapists work closely with the Team Physician in order to provide the most effective therapeutic interventions and rehabilitation of injuries. Their goal is to return an athlete to competition as quickly and as safely as possible. Not only do they play a key role in injury identification, evaluation, and management, but are also critical at the sideline for screening for concussions to mitigate the risk of permanent brain damage.

 

One of the challenges faced by an Athletic Therapist is determining whether an athlete should be removed from activity for further evaluation after a suspected hit to the head. Although even a decade ago it was acceptable to “shake it off” and return to play, new legislations in Canada and the US and standard guidelines require athletes to be removed from competition or practice if a concussion is suspected. To properly determine the risk an Athletic Therapist should complete a post-injury assessment and compare it to a test done on the same athlete at the beginning of the season. In some sports leagues, there are multiple Athletic Therapists tending to multiple teams. A reality is that a post-injury test may not be completed by the same person who did the pre-season assessment. It is important for sports medicine teams to try to manage assessment variances in order to provide the best possible information for making return-to-play decisions.

 

Managing variability through diversification 

The post-injury assessment includes a series of questionnaires, checklists, and physical testing that is identical to the pre-season test. A concussion can impact brain function in a variety of ways and because of the nature and physical demands of a sporting event an evaluation of concussion-related symptoms can be challenging. For example, an athlete may show concussion-like symptoms if they are dehydrated or have performed a strenuous activity, however this does not mean that the athlete will also demonstrate balance or neurocognitive impairments. Therefore it is important that an Athletic Therapist, his/her team and the team physician are all using a comprehensive battery of tests to assess brain function. Relying on any one type of test for the monitoring and decision making regarding return to play for an athlete provides an incomplete picture of the severity and breadth of the brain injury.

 

Managing variability through calibration meetings 

Assessment variances also happen when training and communication is limited between therapy teams. It is possible to estimate and to some degree calibrate inter-rater (tester 1 vs. tester 2) reliability. For example, when testing balance at the beginning of the season, teams can grade athlete balance errors individually and after the test is complete they can compare scores. While this provides a crude measurement, it will provide insight into how much agreement exists and provides an opportunity for coaching and education. Weekly “calibration” meetings may also help - short dedicated discussions can happen and ATs can discuss why they chose the specific values they did. Where disagreements appear, the collective unit can help form some rules to help ensure calibration in the future.

 

Managing variability with routine 

Variability can also appear as a result of intra-rater (tester 1 vs tester 1) reliability issues. For example, grading a balance video in the morning, and then watching and grading the same video in a different setting in the afternoon can generate some significant variances. With the challenges and pressures that Athletic Therapists face during a sporting event combined with subjective concussion testing, a consistent routine and method can help improve intra-rater reliability. To begin, the trainer needs the support needed from his/her therapy team to focus exclusively on the concussion assessment at hand instead of  attempting to split his/her attention between the test and the active game. Reducing situational interference (distractions from the surrounding environment) and following a consistent testing structure or methodology every time can also help.

 

Managing variability with objectivity 

Technology has enabled us to collect objective measurements where subjective grading used to take place. In his Sensorimotor Physiology lab at UBC, PhD candidate Harrison Brown developed a way to use technology to reduce variances in balance testing. He specifically looked at the balance test done in concussion assessments. By analyzing the movement of athletes performing the test and by introducing motion sensors, he was able to develop an algorithm which can objectively score an athlete's balance. “Now it doesn’t matter whether my grandma is doing the test, my favourite doctor is or both; they’re both going to get the same score.” His technology has increased the test-retest reliability of the concussion gold-standard balance test from between 40-60% reliability to over 91% reliability.