As shown previously on this site, (here, here and here) concussion is a serious threat to athletic development and can plague athletes years after they have retired from sport. Post-concussion syndrome, as in the case of linebacker Ted Johnson, can lead to a very dark place and can create a legacy of pain and havoc. Alzheimer’s is much higher in American football players and boxers compared to the general populous.
Sahler and Greenwald published a review of the current assessment tools and return to play protocols. They point out that unfortunately, the SCAT-2 adopted after the 3rd Zurich conference in 2008, has very little evidence supporting its efficacy as a screening tool. This is VERY unfortunate since it is free and is endorsed by the IOC, the IRB (International Rugby Board), IIHF (International Ice Hockey Federation) and FIFA. This is a high profile tool at the disposal of literally tens of thousands of coaches worldwide. One would hope that in the near future, some tests establishing baselines and efficacy standards come about.
The authors point out that a baseline pre-season must be established with the SCAT-2 since there is no cut-off recommendation for return to play (RTP) and it is at the discretion of every coach or therapist on the side lines to interrupt their athlete’s results as they see fit. This is not ideal. Having standards to go by increases generalization across sports, genders and age groups and will maximize chances that the tool will be used correctly. They also cite Jinqui et al 2012 who tested 214 high school athletes without concussion. It was found 67% of high schoolers could not recite the months of the year backwards and 41% could not recite a 5 digit sequence backwards. This raises questions about the applicability of the SCAT-2 to all populations.
Other tools currently available (either for free or at cost) include the ImPACT, the BISQ, the ANAM, the CRI and the SAC. The authors discuss that any assessment used should include a neuro-cognitive component. In 83% of cases, collegiate athletes with a concussion displayed poorer neuro-cognitive scores.
A head CT scan is another method. While expensive and generally high in radiation, a head CT can help rule out other pathologies or secondary problems. The Canadian CT guideline is a Glasgow Coma Scale <15 more than 2 hours after the initial impact OR bilateral racoon eyes, skull fracture, more than two episodes of vomiting in less than 2 hours, over 65 years old. This protocol has 100% sensitivity to neurological problems that require surgery. Unfortunately, specificity varies from 40-80%, so some minor modifications to the protocol are likely to come over the next few years.
The best RTP protocol continues to be the Zurich conference protocol as detailed in our earlier article. The protocol has 6 steps with a minimum of 24hrs between each one. Thus a player with a concussion must wait at minimum 1 week before returning to full play. However, Pelman et al 2005 point out that in some cases, NFL players have demonstrated the ability to come back and play same day at games with no consequences. This continues to point out that lack of studies and guidelines leave coaches and therapists holding the bag and in some cases, financial decisions may over take long-term health.
In a disturbing statistic, 50% of ER physicians told those with mild TBIs that they had no concussion- this should prompt better assessment tools at the medical level and better training. 9% of patients returned to play too early and returned to the ER, 60% were given no advice regarding RTP protocols and a mere 30% were diagnosed and given a protocol. The authors go on to cite Anderson et al 2004 pointing out that 50% of sport concussions worldwide at the elite level are from heading the ball in football. This is another warning sign that requires some modification. If a non-contact sport is responsible for 50% of all concussions, some minor tweaking may be needed. While awareness of football concussions is rising, most parents are far more concerned with rugby, wrestling and American football and few consider heading the ball a high-risk activity.
Clearly more work needs to be done in this field to ensure the safety of participants but we are in a far more informed position. Talks are under way for a 4th international conference with an emphasis on prehab, rehab and return to play.