Beruflich Dokumente
Kultur Dokumente
a r t i c l e
i n f o
Article history:
Received 16 October 2013
Accepted 16 October 2013
Key words:
Mild traumatic brain injury
mTBI
Concussion
Return to play
RTP
Underreported concussion
Underreported mTBI
mTBI legislation
mTBI clinic
Pediatric
Adolescent
Athlete
High school
a b s t r a c t
Background: High school athletes who sustain a mild traumatic brain injury (mTBI) or concussion are required
to be removed from play until clearance by a provider. A regional pediatric trauma center offered an mTBI
clinic to evaluate students for return to play (RTP).
Methods: An mTBI clinic was developed in collaboration with a high school district containing three schools.
This program evaluated students suffering from sports-related head trauma, specically football injuries.
Community mTBI education was performed, a standardized RTP algorithm was developed, and a postseason
survey was administered to football players.
Results: Twenty-eight students playing football were seen by the mTBI clinic. The average time until RTP for
clinic patients was 16.9 days. Four hundred ve players were surveyed. Of players responding to the survey,
40 (15%) reported sustaining an mTBI during the football season. Of those sustaining an mTBI, 9 (22.5%) did
not report their symptoms.
Conclusion: Although the mTBI rate is similar to reported rates, the unreported mTBI episodes were lower
(22.5%) than previously published self-reported mTBI rates. The RTP algorithm was successful in returning
athletes in 16.9 days. The algorithm and data can be utilized by other organizations in establishment of an
mTBI clinic and RTP program.
Corresponding author at: Santa Barbara Cottage Hospital, 400 Pueblo W. Pueblo St,
Santa Barbara, CA 93102, USA. Tel.: +1 805 259 5646.
E-mail address: ekelleher@sbch.org (E. Kelleher).
0022-3468/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.10.016
342
developed an algorithm for treatment and RTP for use in a new mTBI
clinic. Two assessment tools were utilized in the program. ImPACT is
a computerized neurocognitive evaluation that is administered prior
to exposure to at-risk sports. It may also be utilized in evaluation after
concussion and prior to RTP by comparing to preinjury results. All
students playing football underwent ImPACT testing. The Acute
Concussion Evaluation (ACE) [10] is endorsed by the CDC. It provides
information about initial injury and symptoms, persisting symptoms,
concussion history and other risk factors for longer recovery periods.
Additionally, it incorporates management guidelines by provision of
red ags necessitating clinician reassessment and the effects of
exertion as at rest symptoms resolve. The school version also contains
a graded return-to-play explanation and recommendations for
student reintegration into school.
Atthetimeofinjury,athletictrainerscompletedtheAcuteConcussion
Evaluation(ACE)formwiththedetailsoftheinjury.Thisformwasgivento
theparentsofstudentathletes.ParentschoosingtousethemTBIclinicfor
RTP clearance for their child were then scheduled for the next available
appointment. Those appointments included mTBI symptom screening
andaneurologicalexam,andifIMPACTscoreswereavailable,theywere
reviewed. Athletes were evaluated according to the RTP algorithm
(Fig. 1). This was developed based on assessment tools, the neurologic
examoftheathleteandthe1997AANguidelines[11].Thenumberofprior
concussions, grade of concussion, and duration and type of symptoms
were incorporated into an individualized RTP plan.
For athletes who were asymptomatic at their clinic visit, the
completed ACE form for return to school was reviewed with students
and their parents. This outlined that they could return to school when
symptom-free and after an additional RTP algorithm specied rest
period as well as additional recommendations for school reintegration. Athletes and their parents were educated on brain rest and the
risk of reinjury including second impact syndrome. Athletes and
parents were also educated on a graded return to homework and
school. For symptomatic athletes rescreening occurred after the RTP
algorithm specied interval and, if appropriate, athletes were cleared
for graded return to play at that time. If symptoms persisted beyond
2-week referral to a specialist (i.e., cognitive therapy, neurocognitive
testing, and neurology) was performed. Data collected included
information based on ACE evaluation, including initial and ongoing
symptoms. Data were de-identied and collection was approved by
the institutional review board of SBCH.
1.3. Postseason survey
A post-football season survey was provided to all football
participants in the pilot program high schools. The time period
evaluated in the survey was the football season, from the preseason in
August 2012 through the end of the season in November 2012. The
survey provided a basic denition of an mTBI and asked seven
questions related to mTBIs, including 1) whether the athlete sustained
an mTBI this season and/or in past seasons, and 2) if sustained during
this season if and to whom he reported the mTBI, and 3) the licensed
provider who performed the RTP clearance. Surveys were administered by the athletic trainers at the end of the last football game and
returned to trauma services. No personal identifying information was
required on the survey and data collection was approved by the
institutional review board of SBCH.
2. Results
2.1. Clinic demographics
Twenty-eight male football players were evaluated in the clinic.
The average age of students evaluated in the clinic was 15.3 years
[1318]. The most commonly reported symptom by patients seen for
RTP was headache (90%) (Fig. 2). Most students seen in the clinic had
at least one prior concussion (17/28; Fig. 3). The mean amount of time
until RTP was 16.9 days (range = 539).
2.2. Postseason survey
A postseason survey was distributed to the 405 high school
students playing football eligible for the program. There were 266
respondents and the average age was 15.5 years. Of those responding,
40 (15% of survey responders) had reported having had symptoms
consistent with an mTBI during the football season. Of those
sustaining mTBI based on these symptoms and responding to the
survey, 9 (22.5%) did not report their symptoms to anyone, 18 (45%)
Number of Patients
30
343
Headache
25
20
Difficulty
Concentrating
Dizziness
15
Mentally Foggy
10
Noise Sensitivity
Light Sensitivity
Fatigue
344