Dr. Echemendia did think, however, that the length of time players experienced amnesia after a concussion was a telling factor in how severe the concussion was, and thus how quickly the player can return to the field. “Do we have a posttraumatic amnesia that exists for a minute or do we have one that is 12 hours long? It is important to take a look at that,” he said.
Another major problem with most current return-to-play criteria is that they rely heavily on athletes’ reporting of symptoms to assess whether they should return to play, according to Dr. Echemendia. But as Dr. Kirkendall pointed out, players will “lie, lie, lie to get back in a game.” Dr. Echemendia concurred and recommended that “When a player is standing in front of you and they look dazed or goofy, and they are telling you that they are absolutely fine, don’t take their word for it.”
Dr. Echemendia gave another reason for not relying on players reporting their symptoms, which is that they may not even be aware of them. He also noted that some concussion symptoms, such as headache, are so common that they are difficult to distinguish from other conditions. He pointed out that nearly one-third of the athletes he studied reported concussion symptoms at the beginning of the study, before experiencing any head injuries on the college playing field. “If we base our return-to-play decisions solely on their reports of symptoms, then we end up in trouble,” he said.
Dr. Guskiewicz called for more objective, quantitative measures of impaired brain functioning that would disqualify a concussed, brain-injured athlete from returning to the playing field. Those measures would include neuropsychological assessments as well as objective measures of posture and balance. As an example of the need for better assessment, he brought up the problem of balance, which is often disturbed in people after a concussion. And yet, most assessments of balance are inadequate and inconsistent. “One person may think that the individual has a gross sway, and another person may think they have a very mild or moderate sway,” he said.
Dr. Guskiewicz developed a balance error scoring system that enables the accurate assessment of balance. This testing system grades athletes on their ability to maintain a position while standing on one foot and other tasks. The tests require only an inexpensive piece of foam and can be done on the sidelines of a playing field.
Dr. Kelly added that there are devices, such as those that can measure abnormal eye movements, which can also aid the objective determination of certain concussion symptoms.
Several speakers addressed the importance of using neuropsychological assessments in return-to-play decisions. These assessments can objectively determine when a number of brain functions return to normal following a head injury, according to Dr. Echemendia. As he said, “return-to-play decisions are very difficult because we are trying to find that one moment when it is safe to return to play for someone who has a condition we can’t see.” Neuropsychological assessments can help “see” if that condition has resolved, he said, particularly if baseline, normal values in these assessments are known for the players. Such baseline data could be collected by testing athletes when they first come on board a team, prior to the start of any games. Neuropsychological assessments can also determine if some of a player’s symptoms, such as headache, are due to the head injury or some other cause, noted Dr. Echemendia.
But as Dr. Guskiewicz mentioned, neuropsychological functioning is just one piece of a complex concussion puzzle and other factors, such as balance problems and other symptoms also need to be considered when making return-to-play decisions. “There are many pieces to this puzzle, several of which we don’t even know, and you can’t look at just one piece of it,” he said. He also added “no two concussions are created equal.” Some athletes with concussions may do poorly on neuropsychological tests, but well on balance tests, and others will do just the opposite. “That’s why we need to try to make sure that we are looking at every piece of that puzzle in making these decisions,” he said.
Another factor that both Drs. Guskiewicz and Echemendia called attention to was the importance of a player’s concussion history in deciding when they could safely return to play. “The number, spacing, and severity of previous concussions all need to be taken into account,” said Dr. Echemendia. “One of the greatest issues is not necessarily the number of concussions