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Changing How We Detect and Treat Sport Concussions

With another season of scholastic football in full swing at school districts across the country, a growing number of physicians and athletic trainers are re-evaluating how they diagnose and treat head injuries suffered during practices and games. Among the biggest changes is developing different evaluations for children versus adolescents, and incorporating exercise into concussion recovery.

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New guidelines suggest separating patients into two groups: Those ages 5 to 12, and those ages 13 and older, said Patrick Moreno, MD, managing physician of LG Health Physicians Sports Medicine.

Health care professionals typically use the fifth edition of the Sports Concussion Assessment Tool (SCAT-5) and Child SCAT-5, which offers a comprehensive approach and algorithm to determine the risk for concussion. The form was updated last year at the 5th International Consensus Conference on Concussion in Sport. The easy-to-use tool is effective, Moreno said, because of the wide variety of symptoms a concussion may present – from a persistent or severe headache to poor balance, nausea and/or disorientation – and the difficulty in determining whether an athlete truly suffered a concussion. Moreno, team physician for the Lancaster Barnstormers, a professional baseball team with the independent Atlantic League, said the SCAT-5 is now in use by trainers at McCaskey High School, one of Lancaster County’s largest schools, and Linden Hall in Lititz, Pennsylvania, one of the nation’s oldest independent boarding schools for girls.

Concussion treatment is also changing, as Moreno said research now suggests shifting away from complete rest, to incorporating moderate exercise into recovery. While the current treatment plan recommends both cognitive and physical rest – taking a break from schoolwork and getting lots of sleep, for example – that may not always work for everyone, Moreno said. Teens in particular are more susceptible to mood disorders and depression, and lack of exercise can contribute to this. “We’re starting to think that maybe too much rest is not a good thing,” he said.

So, what’s a recovering teen to do?

Growing research shows that low-intensity, low-impact exercise is safe within 48 hours after most concussions, and in some cases, is likely to be beneficial to recovery, Moreno said. Exercise on a stationary bike, for example, can provide cardiovascular exercise without risking head movements that may exacerbate the concussion, and without jeopardizing a patient’s balance, which is typically sensitive after a concussion. Moreno pointed out that all exercise should be conducted after being evaluated by a physician, and while under the supervision of an adult, such as a parent or athletic trainer. Rest remains important for concussion recovery, he said, but combining it with exercise can make a difference in recovery for some patients. The scope of that exercise, however, remains limited.

“The first level of treatment for a patient with concussion is always to remove the athlete from participation,” said Brian Sennett, MD, chief of Sports Medicine and vice-chair of Orthopaedic Surgery at Penn Medicine. “In the past, players were allowed to play if their symptoms cleared, but this is no longer the case.”

Although diagnosis and treatment are important components of concussion care, reducing the risk of sustaining a concussion at all is paramount. Most players undergo a physical exam to be eligible to participate in a sport, and including questions about previous concussions as well as migraines, mood disorders, ADD or even dyslexia can help determine a player’s risk, Moreno said, adding the recommendation of using a computer-based neuropsychological test as a baseline before participation in contact or collision sports such as football or lacrosse. The patient can take an impact baseline test, and then, if he or she sustains a concussion during the season, the test can be used as a comparison diagnostic tool with tests done after the concussion.

Concussion study is a field that’s always evolving, Moreno said, and research is ongoing on everything from reducing risk to treatment plans. And because of this continued research, and in an effort to protect athletes against concussions, athletic leagues are beginning to take precautionary measures in play.

In 2015, the Ivy League found that 23.4 percent of concussions occurred during the kickoff of a football game, Sennett said. With kickoffs only accounting for 5.8 percent of plays in the game, the Ivy League changed its rules and moved the kickoff line from the 35 yard line to the 40, encouraging more touchbacks. 

“This rule has resulted in a dramatic reduction in concussions for Ivy League players, and initiatives like this may be paramount in decreasing concussion rates further,” Sennett added.

While these precautions are reducing concussion rates and opportunities for concussions to occur in play, as the Ivy League announced last week, there are still a lot of unknowns in this area of research. Among them are the long-term consequences of concussions as well developing more definitive diagnostic tools. And, there is no one-size-fits-all treatment for concussions.

“Every concussion is unique,” Moreno said. “We need to tailor treatment based on the symptoms and the individual.”

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