Head injuries create confusion for pediatricians, not just patients

Concussions don’t cause confusion just for athletes.

Recent research on the subject confounds pediatricians, too, making it less clear how to follow guidelines calling for physician evaluation and medical clearance before returning to play.

“With concussions accounting for approximately 9% of all high school athletic injuries, accurately utilizing assessment like these to quickly determine an athlete’s return-to-play probability is critical to long-term athletic and educational performance,” said Anikar Chhabra, MD, MS, of the Orthopedic Clinic Association in Phoenix.

Legal ramifications also are growing, with 21 states having passed laws related to sports-related concussion, generally involving medical clearance, and 21 more states having such legislation pending. In addition, a federal law has been introduced in the House of Representatives, setting minimum safety standards in public schools for management of concussions, also known as mild traumatic brain injury.

Some 12% of all football-related deaths are because of “second-impact syndrome,” in which the fatal head injury occurred in athletes who had “a recent history of concussion, after which symptoms such as headache, dizziness, or memory loss persisted,” according to an analysis of 30 years of data from the US National Registry of Sudden Death in Young Athletes and published in a recent issue of Pediatrics. “In some cases, these athletes were cleared for competition despite residual symptoms from their previous head injury,” researchers said.

The best way to evaluate whether a player is ready to return to play remains controversial, however, because of variations in individual performance and conflicting research results.

Chhabra presented research showing significant variation by sex and individual in results on the Sport Concussion Assessment Tool-2 (SCAT2) at the July meeting of the American Orthopaedic Society for Sports Medicine. As a result, “establishing each player’s own baseline before the season starts and then comparing it to test results following a concussion leads to more accurate diagnosis and treatment,” he said.

But other recent research indicates that baseline testing for concussions in athletes may not have any benefit and may, in fact, harm young athletes. “There is no evidence to suggest that the use of baseline testing alters any risk from sport-related concussion,” according to researcher Christopher Randolph, PhD, ABPP-CN.

Randolph found no prospective, controlled studies of the current version of the most commonly used assessment, ImPACT, and notes that other researchers have found that its reliability “appears to be far too low to be useful for individual decision making.”

Further, he says, the “high false negative rate (ie, classifying a player’s neurocognitive status as normal, when in fact, it is not)” may increase the risk of athletes being prematurely cleared to return to play.