Concussion during sports and return to play decisions

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

I recently read an article in the Archives of Neurology ( Vol 65, Sep 2008) by Dr. Lester Mayers about return to play (RTP) criteria after athletic concussion. As concussions are relatively common sport related injuries (especially in contact sports like football, rugby and boxing) I thought it would be a good idea to review some of the salient points of the article in this forum.

Concussion is a common type of traumatic brain injury and has been referred to by other names such as mild traumatic brain injury, mild head injury and minor head trauma. No good defination for concussion exists though it is frequently described as head injury with transient loss of brain function (usually a short period of loss of consciousness occurs).

Let me explain with the help of an example. I love to box (true one of the few neurologist who actually likes boxing). Lets assume I am going a couple of rounds in the ring with another guy.  A southpaw with a mean right hand. First round here we go!!!. I got my right and left combinations going. Hmmm feeling good and then it happens. I walk into his right. BOOOOOM!!! My knees give in and I hit the canvas. I see stars shining and birds twittering. The referee is asking me “Are you okay? Are you okay?” I look dazed and then slowly come around and answer I am fine. I am helped out of the ring, the fight is over!!! THERE I JUST HAD MY FIRST CONCUSSION!!!

Can I return to play/ box after a 10 mins break?

 Or rather should I return to play after a break?

Is it safe?

 Am I okay?

All these questions are addressed by Dr. Mayers in his review. Traditionally return to play decisions are made by the field side by the team physician or in the case of boxing by the doctor at the ringside. This is usually a clinical judgement with doctors relying on the documentation of resolution of symptoms at rest and during exertion to provide an estimate of the appropiate time for the athletes to resume practice and play (return to play).

A stepwise process was outlined by the Canadian Academy of Sports Medicine:

Step 1: no activity, no play and complete rest till asymptomatic and with a normal neurological examination–if your clear this then Step 2: light aerobic exercise permitted, no resistance training–if you clear this then Step 3: can return to sports specific training and resistance training—if patient remains asymptomatic then can be cleared for Step 4: non-contact training can begin–if patient remains asymptomatic then he is cleared for Step 5: full contact training —if he still remains asymptomatic then he is cleared for Step 6-full play!!! (As you can imagine these criteria are for professional atheletes but also apply for others)

As you can see there are steps to be followed before return to play can be allowed. If you fail one step you go back to the previous step and remain there till you feel better and are ready to proceed further.

Why is this important? Studies have shown that even simple concussions cause cerebral dysfunction (reflecting damage to the brain at the celluar level) and that it takes a minimum of 4 weeks for the brain to revert back to normal. If RTP occurs earlier, the athlete is at risk for a recurrent concussion and further brain damage. Even death can occur (we have all heard of boxers who die during or shortly after a bout).

Learning points from Dr. Mayers review:

1) Concussions are common.

2) Concussions can be serious and even fatal.

3) Concussions lead to cerebral dysfunction and damage to the brain at the cellular level.

4) Return to play decision should be made by a doctor skilled in this task.  A postconcussion RTP interval of at least 4 weeks is imperative (Dr. Mayers takes pain to point out that even more time may be needed to permit complete brain healing and recovery).

My advise to you:

1) Treat a concussion with respect and see a doctor if you suffer one.

2) You may feel you are okay but you are not. The brain takes time to heal completely from a concussion.

3) Do not return to play. See a doctor and get his advise. Let him decide what the return to play interval should be.