you’ve had,” he said, “but how closely spaced they are because it gets to the whole issue of the vulnerability of the brain. If the brain is still vulnerable and you have another concussion, that may lead to a more severe outcome.”

Dr. Echemendia also suggested considering player and team factors such as their style of play and position when making return-to-play decisions. If they tend to “play with their heads” or are in a position that puts them in greater likelihood of experiencing another head injury, then a longer delay before returning them to play may be warranted, he said. Another important factor, he added, is the player’s willingness to return to play. “It is very telling when you have a player who tells you ‘you know doc, I feel scared about going back into the game,’” Dr. Echemendia said. Those players should not usually be returned to the playing field, he said.

Another factor in balancing the risk versus benefit assessment of when players should return to a game, raised by Dr. Echemendia, is the importance of the game and the athletic career aspirations of the player. “Is this an athlete who doesn’t want to go any further than high school in their playing, or is it someone who wants to play at a higher level and just signed a 34 million dollar contract?” he said. “You also need to be aware that the importance of the game might try to pressure you to put that player out on the field too early,” he added.

Another factor to consider is the field conditions, according to Dr. Echemendia. A wet slippery field poses more hazards than a dry one, he pointed out.

Dr. Hergenroeder stressed the importance of having qualified physicians examine athletes who have experienced a concussion before they are allowed to return to playing in a game. As he pointed out, this often does not happen and instead coaches make the decision on when a player can resume playing. “Even well-intentioned coaches are probably not making the right decisions in the interest of the player,” he said.

Dr. Hergenroeder also noted that for many athletes, the sport they play is a major part of their lives and restrictions on their playing can be a hardship for them. To make it easier for these devoted athletes, he suggested that recently concussed players who have no symptoms, but can’t yet return to playing a game, can still work out with their teams during practices and participate in noncontact drills.

“One of the greatest issues is not necessarily the number of concussions you’ve had,” he said, “but how closely spaced they are because it gets to the whole issue of the vulnerability of the brain. If the brain is still vulnerable and you have another concussion, that may lead to a more severe outcome.”

[Dr. Echemendia]

Education

Dr. Brooks presented findings from her study that indicated most of the people involved in high school sports, from the players to the team doctors, were not aware of the seriousness of concussions and how to diagnose or treat them. “We found that most student athletes at the high school level do not have information about concussion,” she said.

Dr. Hergenroeder pointed out that in his experience, the team physicians for many high school and middle school teams tend to be obstetricians, pediatricians, or family practice physicians who have no training in concussion management. “The parents on the sidelines are pleased to know that there is a physician there,” he said, “but this physician may not have the skills for handling some of this.”

Dr. Brooks concurred and noted that when she surveyed family practice physicians within the state of New Jersey, she found that less than half of them felt confident treating concussions. Only a third of them felt confident making return-to-play decisions. And what is perhaps most disconcerting, only ten percent of them received a passing grade on her concussion questionnaire. “We need to educate physicians,” she said.

“Right now family practitioners, internal medicine doctors and pediatricians are the gatekeepers before anybody ever makes it to a specialist like a neurologist or neuropsychologist,” Dr. Brooks said. “If we are seeing that our medical providers do not have the most current upto-date information about what a concussion is or is not, then I think we really have our work cut out for us.”

Although 97 percent of the athletic trainers Dr. Brooks surveyed received a passing grade on her concussion test, 17 percent reported using no objective method to assess concussion consistently, and for deciding when athletes could return to playing a game following a concussion. In addition, 60 percent reported that they had never discussed concussion or return-to-play decisions with their team physicians.



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