Concussion Symptoms and Recovery in Football Players

Abstract

Source: Lau BC, Kontos AP, Collins MW, et al. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011; 39(11): 2311– 2318; doi: 10.1177/0363546511410655Researchers from the University of Pittsburgh sought to determine which on-field signs and symptoms are predictive of protracted (>21 days) versus rapid (≤7 days) recovery after a sport-related concussion in high school football players. Participants included 176 male high school football players (mean age 16.02±1.22 years) from the state of Pennsylvania who were diagnosed with a sport-related concussion by a trained sports medicine professional (ie, certified athletic trainer, team physician) during the preseason or regular season between 2002 and 2006. On-field signs and symptoms were observed and documented by the trained professional at the time of injury and included confusion, headache, loss of consciousness, post-traumatic amnesia, retrograde amnesia, imbalance, dizziness, visual problems, personality changes, fatigue, sensitivity to light/noise, numbness, and vomiting. Participants completed computerized neurocognitive testing using the Immediate Post-concussion Assessment and Cognitive Test (ImPACT)1 within an average 2.4 days after injury, and were followed until cleared to return to play by one of the study’s team of neuropsychologists using international clinical concussion management guidelines.Sixty-nine participants (40%) were lost to follow-up or did not return to football. Of the 107 evaluable athletes, 62 experienced rapid and 36 experienced protracted recovery. There were no significant differences between protracted and rapid recovery groups with regard to pre-injury history of headache, migraine, ADD/ADHD, learning disability, or more than one previous concussion. Mean recovery time in days for the rapid and protracted groups was 4.31 and 29.61, respectively, after correction for outliers. Nine participants’ recovery time fell between 7 and 21 days. The most common measured sign/symptom at the time of injury was headache (94.9%) and the least common was loss of consciousness (13.3%). Dizziness at the time of injury was associated with a 6.34 odds ratio (95% CI, 1.3–29.9; P=.01) of a protracted recovery from concussion. No other on-field signs and symptoms were associated with an increased risk of protracted recovery.The authors conclude that assessment of on-field dizziness may help identify high school football players at risk for a protracted recovery from concussion, which may allow clinicians to manage and treat concussion more effectively in these at-risk athletes.Dr LaBella has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.This study is important because it is the first to evaluate on-field signs and symptoms at the time of injury as possible predictors of prognosis after a sport-related concussion in adolescent football players. Previous studies focused on signs and symptoms at the time of initial clinical evaluation in an emergency department and up to several months after injury in heterogeneous groups of adults with sport- and non-sport-related concussions, with results demonstrating that persistent dizziness was associated with prolonged recovery.2–4 Since many high school football teams have health care providers on site to evaluate injuries and render care, information about signs and symptoms at the time of injury is valuable.The strengths of the current study include a uniform evaluation of all athletes by a team of neuropsychologists who applied the same specific set of criteria to define recovery and determine return-to-play status. Possible confounders such as pre-injury history of headache, learning disability, and previous concussion were accounted for in the analyses. The study’s limitations include a sample comprised of only male high school football players, so results cannot be extrapolated to older or younger players, females, or other sports. Additionally, 40% of athletes were lost to follow-up. Finally, balance was assessed in the enrolled athletes with Romberg, tandem walking, and heel-to-toe walking tests. Postural/balance tests specific for sport-related concussion, such as the Balance Error Scoring System (BESS), may be more sensitive measures of postural stability in athletes.5Despite these limitations, health care providers who evaluate and manage concussions in this population of athletes, especially those providing sideline care, will find these results clinically useful. Identifying dizziness at the time of the injury may allow health care providers to better inform athletes of what to expect regarding the timeframe for recovery and return to school and sports. Furthermore, previous studies2–4 suggest that prompt implementation of modalities to treat dizziness (eg, vestibular rehabilitation) may expedite recovery.