The most recommended therapy following a concussion is rest, physical and cognitive alike. Cognitive rest includes the following: a reduction or a discontinuation of watching television, reading, using the computer, video gaming, texting, doing homework, listening to music on headphones, and using the telephone. All of these activities can exacerbate the symptoms. Driving may especially need to be restricted in athletes with a reduction in their reaction times (Karlin, 2011. Any player with a diagnosed concussion should never be allowed to return to play on the same day, no matter how brief the symptoms are or how well the player looks (“when in doubt, sit them out”) (Karlin, 2011).
The return-to-play protocol is a 6-step process (next figure), where the athlete must be symptom free for a minimum of 24 hours before progressing to the next activity. The American Academy of Neurology has set forth a grading scale (following page) that is recommended when evaluating and managing the concussed athlete, especially in the event of a second occurrence. It may be suggested by a physician at some point that the athlete who has suffered multiple concussions to retire from their sport.
With concussions and CTE being more commonplace in current and former football players, the National Football League has taken a stance with the goal was to make the NFL as safe as possible for current athletes and study the neurological traumas of the retired and former athletes. In 2009–2010, NFL Commissioner Roger Goodell approved rule changes to protect the football player, one of which prohibited an opponent from launching himself and using his helmet, shoulder, or forearm to make contact with defenseless player’s head or neck. The league now requires a second opinion by an outside independent neurological consultant prior to return-to-play (Ellenbogen et al., 2010). The NFL’s ultimate goal was to lead the way in TBI/concussion research, education, and advocacy with hopes that the lower ranks in the sport would soon follow suit (Ellenbogen et. al, 2010).
Since 2008, more than 70 brains have been studied at the Veterans Administration Boston University Center for the Study of Traumatic Encephalopathy brain bank, and 14 of 15 National Football League cases were positive for CTE. We also have found CTE in former professional hockey players, a professional wrestler, and boxers. CTE has also in 17-, 18-, and 21-year-old football players(Cantu and Register-Mihalik, 2011).
Simma et al. states that in order to continue reducing and minimizing the risk for concussions in athletes, several aspects are in need of attention. Athletes’ should be taught to respect the bodies and heads of all players. Appropriately-sized helmets and mouth guards are imperative as is the need to always be “heads-up.” Laws must be passed to ensure there are available trained personnel on-site and return-to-play rules are abided by coaches, players and medical staff. It has been reported that special education resources were provided to only 65% of returning students who needed such interventions at their school (Karlin, 2011).
Furthermore, in a study that focused on the return to school of pediatric and adolescent patients who had sustained a head injury, teachers were aware of their students’ diagnosis only 39.8% of the time (Karlin, 2011). In May 2009, the state of Washington passed the Zackery Lystedt Law, requiring the removal of any athlete suspected of a concussion from the game or practice and requires evaluation and written clearance by a licensed health care provider before being cleared to return-to-play (Karlin, 2011). Parents and athletes must sign a preseason consent form that acknowledges the potential dangers of concussion (Karlin, 2011).
The National Athletic Trainers Association estimates that only 42% of high schools have access to a certified athletic trainer (Karlin, 2011). The Certified Athletic Trainer is well-trained in areas of prevention, clinical evaluation and diagnosis, immediate care, and, collectively, treatment, rehabilitation and reconditioning. Government legislation and sports medicine clinics must work together to help increase the presence of qualified healthcare professionals at the middle-school and high school sports settings.
Meehan III & Mannix (2010) and Karlin (2011) have stated that “lengthy discussions regarding the role of cognitive rest and physical rest in recovery, the risks of cognitive effects, impact on academic performance, and risks of recurrent injury, are unlikely to occur in the ED.” This is evident as a reported twenty-eight percent of children did not receive instructions to follow-up with an outpatient provider after discharge from the ED. As “one of the few, proven, effective interventions in the management of concussion, this is significant, as is early education regarding common symptoms, likely time course, and coping strategies (Meehan III & Mannix, 2010).
Therefore, concussion education must be provided for athletes, their parents as well as their teachers to ensure that the chance of safely recovering from the injury Bravado often prevailed in the past as athletes would hide their concussions symptoms, in fear of being viewed as weak, and thus returning to the game while neurologically impaired. It is with hope that in the “toughing it out” or “playing through it” a thing of the past.