Immediate and long-term assessment of traumatic brain injury in athletes.

One of the most difficult problems facing physical therapists (PTs) specializing in sports injuries is the recognition, treatment, and management of athletes with head injuries. Traumatic Brain Injury (TBI), broadly defined as brain injury due to externally inflicted trauma, may result in significant impairment of an individual’s physical, cognitive, and psychosocial functioning.1

Although sports injuries account for only 3% of hospitalizations for TBI, approximately 90% of sports-related TBIs are mild and may go unreported, thus leading to an underestimation of the actual incidence rate of sports-related TBI.1 The danger of this high incidence is that, once an athlete receives a TBI, the likelihood of sustaining a second one increases by four.2 This phenomenon is commonly known as second impact syndrome. The term mild TBI (MTBI) has been used to describe brain injuries, especially those common to athletics.

Mechanisms, Signs, and Symptoms

Any direct or indirect (rotation) force transmitted to the head can lead to an MTBI. Although protected by a thick, nonexpanding bony vault, the brain is susceptible to several types of injury forces. Direct compressive forces, such as a forceful blow to the resting head, are generally well-tolerated unless they cause focal pathology (such as fractures and hematomas). Rotational acceleration and/or deceleration, on the other hand, creates tensile shearing forces between the brain and its surrounding attachments, resulting in more serious injury.3 Such an injury might occur from the athlete’s moving head striking a fixed object, such as the ground or another athlete. Lastly, MTBI can result from a sharp blow to the athlete’s torso or pelvis.

Rarely are the consequences of an MTBI limited to one set of symptoms. Observable symptoms may be consistent with altered neurological function, a change in cognitive function, noticeable behavioral deficits, and decreased social capabilities. Signs and symptoms of an MTBI can include one or more of the following: brief loss of consciousness, light-headedness, vertigo, cognitive and memory dysfunction, tinnitus, blurred vision, difficulty concentrating, amnesia, headache, nausea, vomiting, photophobia, or balance disturbance. Delayed signs and symptoms may also include sleep irregularities, fatigue, mood disorders, an inability to perform usual daily activities, depression, or lethargy.4 

The onset rate, duration, and severity of these symptoms commonly determine the MTBI classification. Unfortunately, attempts to uniformly characterize and classify the levels of MTBI by utilizing signs and symptoms as indicators of relative severity have been difficult. Sixteen different systems are currently being used in sports medicine to classify or grade MTBI.5 The three most common systems vary slightly, but each is based on two common parameters—consciousness and amnesia.  

Clinical Assessment

The clinical assessment of an athlete with an MTBI is essentially no different from any other emergency procedure. The objectives in evaluating the potentially head-injured athlete are threefold: recognize that a head injury has occurred; determine which athletes require transport to a medical facility for further treatment or diagnostic testing (such as a computed tomography scan or magnetic resonance imaging; and following the appropriate treatment, decide when the athlete may safely return to participation.6 Due to the serious nature of MTBI and the concern for second impact syndrome, it is recommended that a physician make this decision.4

Although there is not one universally recognized evaluation progression, all athletes suspected of having sustained an MTBI should undergo neurological screening (eye, ear, cranium, cervical spine, sensory, and motor examination), mental status testing, and exertional proactive testing.4 These tests not only determine the severity and classification of the MTBI, but they may help the return-to-participation decision to be more objective. In addition, the findings may lead the physician to refer the athlete for diagnostic testing before any return-to-participation decision is made. Critical analysis of mental status testing and the return-to-participation decision are necessary for practitioners to develop their own MTBI management techniques.

Mental-Status Testing

Mental-status examinations must include short-term memory tests to assess the athlete’s ability to process new information. Memory loss of the events preceding the injury (retrograde amnesia) or the events following the injury (post-traumatic amnesia) constitutes a common mental status abnormality.

Practitioners have struggled to standardize their approach to mental status testing. The Standardized Assessment of Concussion (SAC) provides rehabilitation specialists and physicians with a rapid (5-minute) and simple sideline-evaluation instrument for assessing athletes with MTBI.7 The instrument tests attention, concentration, short-term memory, and delayed recall. However, it does not replace a neurological examination.

More detailed mental-status testing with a battery of standardized neuropsychological tests is being used in a similar fashion in many levels of athletics.8 These evaluations, some computerized, can objectively measure cognitive deficits. Results can be compared with both preseason and/or normative data to help determine the status of an athlete’s MTBI. Research using neuropsychological testing is designed to delineate the acute recovery curves associated with specific signs and symptoms of MTBI.9 

The neuropsychological evaluation is most effective when it includes a baseline assessment of the athlete’s preinjury level of cognitive functioning. Evaluation, after the injury has occurred, should be completed within 24 hours. This involves a careful assessment of specific cognitive functioning such as memory, attention, and information-processing speed. Researchers believe that detailed standardized neuropsychological evaluations more adequately assess these domains than do the sideline mental-status tests like SAC.9

More research and normative data are needed before practitioners can accurately interpret results from injured athletes. For instance, cognitive test performance can be an indicator of mental status improvement during subsequent evaluation, or the neuropsychological improvement could be attributed to possible learning effects. Correlations between various cognitive tests should also be questioned. Additional research in this area will enhance the practitioner’s ability to use these tests and subsequently improve return to participation decisions.

Return-to-Play Guidelines

Just as with the definition of MTBI, there are no universally accepted criteria for determining—on the basis of symptoms—when an athlete may safely return to participation. Determining return to play is not based on the classification or severity of the MTBI. Rather, return to participation on the same day as the injury is recommended if signs and symptoms are clear within 15 minutes or less, both at rest and exertion; the neurological evaluation is normal; and there is no documented loss of consciousness. The athlete is not allowed to return to participation on the same day if signs and symptoms do not clear within 15 minutes at rest or exertion, or if there is any documented loss of consciousness.

There continues to be ongoing concern, however, regarding the lack of scientific method used in constructing each of these management guidelines. Some argue that the guidelines are empirical and reflect the biases of their creators, as well as an overall fear of second-impact syndrome or death.6 For example, there are no data to support the 15-minute distinction for return to participation, nor is there any accounting for individual variability in symptoms. Further, the guidelines assume a standard for all athletes regardless of age or skill level.

Continually re-evaluating the signs and symptoms until they disappear, as well as monitoring the athlete’s mental status through neuropsychological testing, may lead to greater success in preventing reinjury. Not all MTBIs can be prevented. Still, the sports medicine community continues to strive for more accurate and consistent management, as well as an appreciation for the need to treat each case individually, thus decreasing the potential for reinjury and subsequently reducing the long-term effects associated with MTBI.

Long-Term Management

Athletes with severe TBI will not pass any return-to-play guidelines. If the athletes are too physically and cognitively impaired to be managed by family members at home, long-term care in a rehabilitation center may be the best option. The decision to place a TBI patient into a long-term care facility is not solely a therapeutic matter—it is also a difficult family and financial matter.

When PTs at outpatient clinics are faced with the prospect that the athlete with TBI who they were training must enter a long-term facility, they must consider many things. All relevant patient data, including assessment test and treatment details, should be passed on to the long-term care facility. In addition to the basics, the outpatient PTs should also pass on as much information about any specific behaviors the TBI athlete is exhibiting, and the best approaches that the outpatient PTs have found for getting the patient to be compliant with the treatments at hand. It is also critical to share data about range of motion to ensure that the patient does not develop irreversible secondary changes due to spasticity or unnoticed heterotopic bone ossification. In addition, it is important to exchange the patient’s Ranchos score, which serves as a starting point about the level of conciousness.

It is very important that long-term facilities that accept TBI patients have prior experience and training with the distinctive characteristics that can accompany the diagnosis. It is imperative that the staff has a basic understanding of behavior-management techniques, and is able to act as a team when treating TBI patients. Programs and services that should be considered are family education, cognitive stimulation by skilled and ancillary staff and families, restorative range of motion, and agitation-management programs.

Tory R. Lindley, MA, ATC, is the head athletic trainer at Northwestern University, Evanston, Ill.

References

1. NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury. Rehabilitation of persons with traumatic brain injury. JAMA. 1999;282:974-983.

2. Cantu RC. Guidelines for return to sports after a cerebral concussion. Physician Sportsmed. 1986;14(10):75-83.

3. Bruno LA, Gennarelli TA, Torg JS. Management guidelines for head injuries in athletics. Clin Sports Med. 1987;6(2):17-29.

4. Wojtys EW, Bailes J, Boland A, et al. Current concepts: concussion in sports. Am J Sports Med. 1999;27:676-687.

5. McKeag DB. The head injured athlete. In: Proceedings at the Annual Meeting for the American Medical Society for Sports Medicine; June 3, 1998; Orlando, Fla.

6. Echemendia RJ, Parker ES. Neuropsychology: evaluation and testing. Ethical issues. In: Bailes JE, Lovell M, Maroon JC, eds. Sports-Related Concussion. St Louis: Quality Medical Publishing Inc; 1999:157-170.

7. Kelly JP, Rosenberg JH. Diagnosis and management of concussion in sports. Neurology. 1997;48:575-580.

8. Cantu RC. When to return to contact sports after a cerebral concussion. Sports Med Digest. 1988;10:1-2.

9. Report of the Sports Medicine Committee: Guidelines for the Management of Concussion in Sports. Denver: Colorado Medical Society; 1991:1.