Neuropsychological testing should include measures of concentration, motor dexterity, information processing, visual and verbal memory, executive function, and brain stem function.19 Testing can be performed in the athletic setting with a Web-based computer program, by a sports medicine specialist with an interest in concussion, or by a neuro-psychologist with expertise in concussion.
Improvement in cognitive function as a concussion resolves may come prior to, or follow, the resolution of clinical symptoms. Therefore, it is important to properly assess cognition and symptoms before you make a recommendation about returning to play.3,10 Baseline performance parameters must be established before the season starts.
Neuropsychological testing can provide both an objective measure of the neuro-cognitive effects of concussion and the ability to track recovery. It may also assist in making return-to-play recommendations in complicated cases, but bear in mind that no data are available to suggest that return to play is safe once neuropsychological testing has returned to normal.3,9 Test results can aid clinical decision making, but cannot substitute for it. Testing may be most helpful in athletes with repeated concussions or those with persistent symptoms.10
Educating athletes, parents, and coaches in prevention
No foolproof method exists for preventing concussion in sports. Sports medicine research has focused on designing and testing safer equipment and on devising new rules to make play safer.20-22 At present, there is no evidence that protective equipment will prevent concussions, but recent studies by Collins and Viano suggest that newer football helmets may assist in decreasing the incidence of concussions.20,22,23
The Zurich consensus statement warns that protective equipment can have a paradoxical effect, influencing athletes to take risks that they might otherwise avoid, thus increasing injury rates.5 Trials of rule changes in different sports have been and continue to be conducted, such as barring spearing in football and restricting helmet-to-helmet hits. Given the frequency of concussion, further research is clearly needed. In the meantime, family physicians can play a major role in educating players, parents, and coaches about the seriousness of concussive injury and the need for identifying concussion promptly and allowing adequate time for recovery.
What do you tell Jeff?
Your answer for Jeff is, “You’re not ready to go back to practice or play. You feel OK when you’re resting, but when you get up, your headache returns. Come back to the office in a day or 2, and I’ll re-evaluate you. If you don’t have any symptoms then, you can start a program of graduated activity, beginning with some light aerobic exercise. If you feel all right with that, you can go on to a moderate and then an intense aerobic workout. If you still feel good, you can go on to sports-specific activities with no contact training, and then full contact training.
“At each stage, you will need to be re-evaluated by me or by your team trainer. Once you’ve finished the program without any reactivation of symptoms, I’ll clear you for play.”
CORRESPONDENCE Shawn M. Ferullo, MD, One Boston Medical Center Place, Boston, MA 02118; Shawn.ferullo@bmc.org