Complete Rest After Concussion May Not Be Best Prescription

Exercise May Actually Help After Concussion? https://t.co/dash57gqAL pic.twitter.com/qrzofSaD0S

— ScienceDaily (@ScienceDaily) April 30, 2016

This report from the 2016 Pediatric Academic Societies meeting adds to a growing body of evidence suggesting that children who get low risk exercise even while still having post-concussion symptoms may actually have shorter recovery periods.

One may rightfully wonder if there is some selection bias in these results- kids who may have felt less burdened by concussion symptoms naturally tried to return to exercise sooner. Further study will have to explore this potential phenomenon.

Overall, I think these findings and the outcomes of similar studies provide support for a more active post-concussion recovery monitored by qualified health care providers and not just predicated on rest and watchful waiting.

The proper time to start such active recovery is not certain and likely will be an individual matter as well.

This does also bring up the fact that many current concussion return to sport policies recommend or even require that athletes must be symptom-free before being allowed to return to any form of exercise.

If continued study indeed adds support to the role of appropriately monitored and prescribed exercise to enhance recovery, then these policies, such as the California Interscholastic Federation return protocol, will need to be amended.

Rather than a "one size fits all" uniform pathway, allowing some measure of flexibility may also provide beneficial when determining starting points and type/amount of exercise.

Otherwise medical experts and school officials are possibly restricted in utilizing exercise to aid in recovery and this limitation may actually be slowing the improvement of concussed athletes.

Are Past Unreported Concussions Often Found in Pre-Season Assessments?

The use of baseline assessments to provide comparison data for future concussions provokes controversy about validity, cost, and time investment. If however, such testing routinely uncovered past unreported or even currently symptomatic concussions, would that influence opinions about the significance of such efforts?

Definitely curious if others have found significant numbers of previously unrecognized concussions in their preseason testing?

I met recently with administrators of a local contact/collision sport league who wanted to discuss their pre-season baseline testing program for concussion monitoring.

They have developed an amazing concussion program, complete with education, pre-season testing, surveillance, and return-to-play protocols.

Coaches or team administrators are required to report all suspected or confirmed concussions to league officials for follow-up monitoring of medical evaluation, treatment, recovery and return progression.

The leagues they supervise are growing, with now over 1000 athletes on multiple teams in several cities.

That means the potential of more pre-season evaluations, and whether the medium is computer or paper based, with or without functional testing such as vestibular or visual testing, we all know that this takes time, effort and tends to have a bunch of logistical issues.

So, not unacceptable to find ways to reduce the early season demands but still provide adequate data to analyze players after a concussion.

With the ability to compare post-injury results to solid age-matched normative data sets for many of the neurocognitive platforms, some have begun to question the utility of the time and expense for routine annual baseline testing.

Others have offered the opinion that every other year evaluations might suffice in the school-aged population and thus reduce some of the testing burden but not lose the value of the data.

These both sounded like workable options for this league to consider, until one eye-popping revelation was shared.

Realize, we're talking about a close-knit sport community where kids and families know each other well and administrators have designed a visible program that requires reports of all potential concussions, with penalties in place for failure to report.

You’d think that there wouldn’t be too many concussions that could sneak by so many watchful eyes.

Guess again.

A critical review of the pre-season data found a startling disconnect on many teams between the number of concussions officially reported to the league and the number of concussion the kids report in their baseline testing.

When asked to report either number of concussions or current possible post- concussion symptoms, the players admitted to a frankly startling number of concussions, including dates of injury, that were never officially entered into the league data base.

Now perhaps this shouldn’t have been so surprising to those of us having this conversation.

We always worry about under-reporting at the time of injury, not just by athletes, but also unfortunately by adult coaches and parents all eager to limit or eliminate any missed playing time.

Have also learned another thing when working with kids- when it comes to answering questions about symptoms or past concussions, kids just can’t seem to lie to a computer..

They might repeatedly deny past history or current problems to a medical provider in person, but when asked to report information to a computer, the flood gates tend to open.

I must give big-time credit to these league officials for underscoring the importance of their active, critical review of all baseline testing and not just passively collecting data for potential future use.

Their use of the computerized baseline testing information apparently allowed a better look at the true incidence of concussions, and unfortunately, a more realistic look at sandbagging or failing to report.

Now, I’m not entirely ready to endorse a punitive Orwellian “1984: Big Brother is Watching” approach to concussion management.

I still think trust and transparency between all parties is absolutely essential.

I’m also not totally on board with the absolute need for computer-based platforms for concussion evaluation or record keeping for that matter (often handwritten mediums provide sufficient information).

But if an annual computerized pre-season assessment  provides candid responses that reveal sufficiently high numbers of previously unreported or even worse, incompletely healed concussions, then maybe all that work, all that effort, and all those logistical efforts suddenly seem far more justified.

Very curious if other organizations performing large-scale pre-season baseline neurocognitive evaluations have seen a similar difference between “official” concussion reports and those self-reported on computerized assessments?

Is the above experience an isolated phenomenon, or is it worthy of further collaborative study?

Thoughts on California Interscholastic Federation Concussion Return Protocol

Right before California Assembly Bill 2127 became law on January 1, 2015, I wrote on this blog many questions remained unanswered about certain provisions, namely clarifying what is meant by "no less than a seven day" return progression, when does this seven day period begin, and a better definition of appropriate supervision during this period.

Today, after reviewing the recently released California Interscholastic Federation (CIF) Concussion Return to Play Protocol, it is now readily apparent that the intent of the law was to ensure that if an athlete was concussed let's say on a Friday night, that they will not be able to return to play the following Friday night.

This comes as no great surprise to many of us in the sports medicine community and serves to bring uniformity to something that we had suspected since the bill was signed into law.

There are several other provisions of the Return to Play progression that should be of unique interest, and I will list them below along with my professional comments:

• Return to play cannot be sooner than 7 days AFTER the diagnosis of a concussion by an physician MD/DO
  • Now we know when the "clock can start" and what concerns me is not so much the sports with one game a week, but those with multiple games a week.
  • If a football player is concussed on Friday night, having the physician evaluation the following Monday or even Thursday doesn't have a real time sensitivity since that athlete is out for that next week's game and still has the seven day period potentially available to play in the following weeks game.
  • However, let's take the case of a basketball player with a tournament that involves key games possibly 8-9 days after a concussion. There might be pressure placed on the physician to see that athlete ASAP to get the clock started for a potential return in that 8-9 day period
• No physical activity for at least 2 full symptom-free days AFTER you have seen a physician 
  • Given the emphasis on the no return within a full week after a concussion, can certainly see why this element was put into place.
  • Does limit the judgement of medical teams to allow light, low-risk activities that might be well-tolerated in the initial post-concussion period and may also actually assist in that recovery.
• A certified athletic trainer (ATC), physician, or identified concussion monitor (e.g., coach, athletic director), must initial each stage successfully passed
  • Leads to an increase in the paper trail but also makes each school responsible for monitoring a step-wise return to play and not just allowing a full immediate return to sport. 
  • Hopefully this provision will further underscore the important role of a certified athlete trainer on a school campus. For those schools that don't have one, this might serve as a strong motivator to find necessary resources to support the hire of an ATC to help maintain compliance with this new law.
•  Minimum of 6 days to pass (non-contact) Stages I and II. Prior to beginning (contact) State III, please make sure that written physician (MD/DO) clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor. 
  • That 6 day minimum again written with a direct eye on football and not having an athlete return for that next game after a concussion
  • Here's another spot where having an ATC can make the process easier- as a physician, if I have a strong working relationship with an ATC, I might not need to see the athlete back in my office before allowing return to contact if the ATC is comfortable with the return protocol and progress of the individual athlete.
  • Now, if there is no ATC on campus, stronger chance that I will require an office visit between non-contact and contact return.
• MANDATORY: You must complete at least ONE contact practice before return to competition. (Highly recommend that Stage III be divided into 2 contact practice days as outlined above.) 
  • Remember that AB 2127 also limits full contact  practices to only 2 ninety minute sessions per week. 
  • Curious to see how a return to play that recommends 2 contact sessions works out with these new contact practice limitations

I will close out this post with a  passionate request to CIF and the sports and school communities: despite any concerns or disagreements, this protocol is now in place and thus must be publicized, discussed and shared through multiple mediums to get the word out to all coaches, athletes, parents, administrators, and medical providers. . I can honestly say that with past state or CIF concussion policy updates, I was shocked at how often reasonable, involved, and usually well-informed colleagues were unaware or ignorant of these changes. If all schools are following the same protocol, there will be more universal acceptance of this new policy, so CIF cannot passively oversee dissemination, it must take a very active and vocal role to increase the appropriate use and eventual greater acceptance of this new protocol.

Studying Role of High School Principals in Return to Learn after Concussion

If there isn't enough frustration and feeling of being overwhelmed after suffering a concussion, the process of returning a student back to academic work can only seem to magnify those concerns.

While return-to-play progression protocols have been established to assist in getting athletes back to sport, similar return-to-learn programs have lagged behind.  The sheer complexity of  meeting particular needs and schedule demands of each student requires an individualized plan created with appropriate understanding of expectations and optimal communication between medical professionals, families and educators.

Often, recommendations include  designating a point person who can advocate for the student and family by communication with fellow educators and monitor of student progress.  This same person might also provide on-going dialogue with outside medical providers. However, finding a person with appropriate knowledge and desire to accept and carry out these roles can be difficult. 

A school-based concussion management and response plan can provide further framework to delineate expectations, potential adjustments, and roles, though the actual implementation and utility of such plans has not received much study.

Given the common findings of frustration and lack of apparent coordination in the return to learn process, I was excited to review the article HIgh School Principals' Resources, Knowledge, and Practices regarding the Returning Student with Concussion  in an effort to gain unique and previously unreported insight into school-based resources and management strategies.

Using a cross-sectional computer-based survey of 465 urban, suburban, and rural public high school principals in the state of Ohio, key findings of this study included:

• Just over 1/3 of the principals had completed some form of concussion training in the past year, with those who completed such training have higher self-reported concussion knowledge scores and were more likely to have provided or supported concussion training for school faculty who were not directly involved with youth sports
• When identifying a point person, athletic trainers were most often reported, but about 1/5 of respondents did not know or designate a point person at their school. Schools that identified  more than one point person tended to  have more students, a principal with higher self-reported concussion knowledge, and to have a full or part-time athletic trainer.
• Athletic trainers were reported as the main agents of communication with medical professionals for concussed student-athletes, while school nurses and counselors assumed this role for concussed students who were not athletes. Principals, assistant principals, and guidance counselors assumed the primary role of communication with parents for all students  (regardless of athlete status).
•  When asked to respond to a list of short-term classroom adjustments commonly recommended for concussed students, over 90% of principals agreed with all or most of them, with just over 30% requiring a health care provider note to initiate the adjustments.
• Several principals reported a school response-to-intervention (RTI) team to assess student needs and to develop an intervention plan in terms of academic adjustments and accommodations.
• About 1/3 of the schools had a written concussion plan, with 75% of those plans addressing academic adjustments and accommodations.

How can we use these findings to better assist our concussed students in their effort to return to the classroom?

• A principal with concussion knowledge is essential- thus ensure more (and hopefully higher quality) concussion training for principals, which could then translate to more training for school personnel, the identification of point persons to assist concussed students, and better communication between principals and the parents of a concussed athlete.
  • Potential avenues include Internet modules from the National Federation of State High School Associations and the Centers for Disease Control and Prevention.
• An athletic trainer is essential- thus ensure that every high school campus has a  certified athletic trainer acting as an advocate for concussed students and being on campus for part/all of the academic day (not just for after-school activities) to foster relationships with teachers and help monitor student developments.
• An intervention team is essential to initiate academic adjustments early after a concussion, preferably without the absolute need of a medical provider note to reduce any obstacles.
• Providing a concussion management plan that delineates roles and expectations and is shared with all key parties (students, school personnel, families and medical providers) to provide education and on-going assessment of the utility of the plan.

What other recommendations do you have to assist concussed students return to learn? Do these recommendations seem reasonable and practical?

Dr. Koutures New Video Presentation Page

Check out new webpage with Video Presentations: 

https://chris-koutures.squarespace.com/dr-koutures-videos/

Current Video Presentations  include:

More to come- suggestions for future Video Presentation ideas eagerly accepted for consideration.

Are California Schools and Medical Providers Prepared for New Concussion Law?

California Assembly Bill 2127 authored by  Assembly Member Ken Cooley (D-Rancho Cordova) will take formal effect on January 1, 2015 and will provide that, if a licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete is required to complete a graduated return-to-play protocol of no less than 7 days in duration under the supervision of a licensed health care provider. This stipulation is an extension of previous California legislative mandates passed in 2011 and 2012 that require:

• Immediate removal for the remainder of the day of any high school athlete suspected of having a concussion
• Prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from a licensed health care provider
• Each year, a concussion and head injury information sheet must be signed and returned by athletes and parent/guardian
• Concussion education must now be part of required first aid training of every high school coach

For my initial reaction to this law, click here

In discussions with coaches, administrators, and fellow sports medicine providers, I'll throw out a few questions that have arose regarding several nuances of the law:

• When is the earliest that the 7-day return protocol begins?
  • Is it potentially at the time of formal diagnosis of a concussion by a licensed provider?
  • Is it when the athlete is fully cleared of post-concussion symptoms?
  • Can the period begin before a formal diagnosis is made?
• What is the formal definition of supervision?
  • Can an athletic trainer assume the role of supervision under the guidance of a physician?
• Given that the bill also limits contact football practices to two 90 minute periods per week, if the timing of those two practices is perhaps a day before a player's progression is ready for contact, can he have alternate contact to possibly play in a game if otherwise having an appropriate recovery?
• Are school and medical providers aware and sufficiently prepared for these new edicts?
  • Is there agreement or clarification on the above terms and concerns?
  • Have concussion management plans, if already in place, been modified or reviewed to address the new mandates?

Certain that there are other questions and thoughts out there- please use this as a forum to share with others.