The ImPACT of Concussion Testing in Young Adults
Dean Clinic Sports Medicine Doctor Deanne Eccles-Rotar explains why baseline testing is so important for student athletes
I have been doing event coverage for sports for 16 years. I started during my residency and have been doing it ever since. One area that has changed the most, in my opinion, is concussion management.
With the advent of computer-based neuropsychological testing and public awareness, things are much different than when I first started. Back then, we used the Cantu guidelines for concussion management and kids with a "bell ringer," who were asymptomatic and passed sideline evaluation tests, were allowed to return to play. With the ability to test these kids after their injury — at 24, 48 and 72 hours post-injury, for example — one can determine that these kids were not ready to return to play. This is especially evident in the younger age groups, who usually require about a week to return to normal test results.
One area that we had trouble with at that time was relying on the athletes themselves to tell us if they were having symptoms. Because athletes have such a high drive to return, they often will tell the athletic trainer or team physician they don't have symptoms. Physical exam findings are often normal as well. Neuropsychological testing has allowed us to have objective data to help with the decision of when an athlete can return to play.
In addition, athletes tend to report symptoms more honestly during the computer test as compared to questioning during an office exam. I think they feel they can't fool the computer, or maybe they feel less pressure to answer the question the way the physician or athletic trainer expects them to answer.
In addition to testing, there has been significant public awareness of concussions thanks to the efforts of legislation and media coverage of it. Wisconsin now has a law on the books, Act 172, which allows coaches, officials or health care professionals to remove an athlete from play who is exhibiting signs or symptoms of concussion. After he or she is removed from play, the athlete is required to obtain written clearance from a health care professional with training in concussion management before being released back into his or her sport.
As a result, we are seeing a greater number of athletes with concussion symptoms come in for evaluation. It is always difficult to determine if they actually suffered a concussion or if the headache they developed after the game was from exertion, illness, dehydration or other causes.
One thing remains a priority — not to return an athlete to contact sports if he or she is symptomatic. With the right testing and clinical exam, we have tools to help us determine if an athlete is ready to return to play.
ImPACT is a brand of testing that is widely used in our area. The ideal way to use this program is to have contact sport athletes get tested prior to the onset of their sport’s season. This is considered a baseline test, and then upon retesting, after a suspected or known concussion, you can use this baseline to compare test results and see if they are equal or better. The test usually contains verbal and visual memory, processing speed and reaction time exercises. The test results, in combination with history, the exam and a discussion with parents or an athletic trainer, can help us guide an athlete back to play more safely.
This testing is not perfect, but it is a useful tool to supplement their history, exam results and parental/athletic trainer input. In this area, once an athlete is allowed to return to sports, he or she is usually put through an approximately five-day progression of cardiovascular activity, drills, sport-specific training and then contact practice before being cleared to return to a game situation. If symptoms develop during the progression, the athlete must stop and restart the next day until her or she has successfully completed the step.
Younger athletes should be progressed slowly, as their cerebral blood flow is more sensitive after an injury and they are likely to take longer to improve. Older athletes, 18+, can be given a quicker progression but confirming the absence of symptoms is always the key to returning to contact activity. Athletes with concussions should limit screen time such as TV, computer use, texting, video games and movies. They may also require assistance with school work and may need to start back to partial days if symptoms worsen upon returning to school.
As we become more knowledgeable about concussions and our ability to objectively evaluate these athletes, we may be able to return these kids to the playing field without the risk of second impact syndrome or chronic mental deficits. I feel that we have made great strides in the last five years, but further advancements are likely to change things even more.