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Sports Injury: Return to Play (RTP)

In the last ten years it has become clear that high school, and even junior high school, sports such as football, soccer and lacrosse pose a danger of acute or chronic brain injuries. The autopsies of football players as young as 16 years-old have shown evidence of CTE (Chronic Traumatic Encephalopathy).

CTE is caused by repeated subconsussive trauma to the brain from physical contact. The repeated trauma creates tangles and plaques in the brain which are similar to those found in Alzheimer’s patients. Not everyone, of course, develops CTE. It is not yet proven but it is suspected that genetic and other traits can make individuals more or less susceptible to developing CTE.

While CTE development is a chronic condition that may or may not include an event involving a concussion, the most common danger involves an athlete being returned to play while suffering from a previous concussion. The increasingly complicated and delicate question of “Return to Play” (RTP) is an issue which is still being fully developed. It has been shown that athletes and others who suffer a second concussion while still symptomatic from an earlier concussion, can develop serious and permanent brain injury. There is also evidence that physical exertion immediately following a concussion can lead to amplification of concussion symptoms and an incomplete recovery. Fortunately, most high schools in the United States now employee trainers who have undergone specialized education in dealing with and identifying athletes with concussions and how to deal with these. Yet – problems continue for the following reasons:

1. There is an immense amount of peer pressure from teammates, friends and parents on an athlete to perform and continue to play.

2. The pressure of year-round training and year-round leagues, some connected with the hope of college scholarships, adds to the pressure as well as the amount of trauma received per year.

3. Athletes can be uncooperative in a school’s attempt to get a “baseline” function (see below).

4. Trainers and coaches are under their own set of pressures to win games and showcase talented individuals on the playing field.

One of the new tools used by schools is called ImPACT testing. This test of motor and cognitive skills was developed by neuropsychologist and neurologist with a great deal of experience in sports injuries. The ImPACT test is given very widely, but parents should keep in mind the following:

1. There should be a “baseline” ImPACT test before the season starts. That way, following a possible concussion, the student can be retested to see if there are deficits in cognitive or motor abilities.

2. Be aware that athletes can often attempt to “dog” the test and achieve a low baseline score, which in effect will keep them in the game even if they have a mild concussion. Review the ImPACT test with your child’s trainer or at least educate yourself on the scoring. There are indications on the testing as to whether or not full effort was given by the student. If there is any question about the validity of your child’s baseline score – ask the trainer to retest the student.

3. Sometimes it’s up to the moms. It is not uncommon for the father of an athlete to be more likely to agree to let the athlete return to play. If either parent has any questions about their child’s return to play, friends of the student as well as boyfriends or girlfriends, should be questioned. The student may be more likely to describe symptoms such as headache, dizziness or foggy thinking to friends than to parents or coaches.

4. Another precaution would be to perform the “gaze nystagmus” test on the student who might have suffered a concussion. This test is also performed by doctors and trainers when appropriate. You simply have the student follow the tip of a pencil with their eyes back and forth, looking for jerking movements of the eyeball at the left and right extremes. The more the jerking occurs, away from the extremes, the more likely there may be a problem. Be aware that some drugs and alcohol can cause this symptom as well.