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Health & Exercise Forum

Safely Return to Play after a Concussion

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May 7, 2009

Guest Columnist: Matthew Scalese, DPT

Pittsburgh Steelers Head Football Coach Bill Cowher recently drew harsh criticism for deciding to start injured quarterback Ben Roethlisberger just one week after sustaining a concussion and being knocked momentarily unconscious.  That criticism was fueled by the fact that Big Ben preceded to throw 4 interceptions in the game (2 returned for touchdowns) and single handedly lost the game to the hapless Oakland Raiders.  Sorry Raiders fans - but your team does stink!!!  The Roethlisberger concussion was his second in a few month span (the first occurring when he crashed his motorcycle in June ) and has Steelers fans hoping their star quarterback’s career won’t be prematurely derailed like other former quarterback greats - Steve Young and Troy Aikman. As an avid Steelers fan, Dr. Matthew Scalese has an obvious interest in this topic and was eager to author this column on concussion and safe return to sport.

Concussions occur when a person’s brain is violently rocked back and forth inside of the skull because of a blow to the head or neck.  Severe concussion, although rare, can lead to brain swelling, blood vessel damage, and even death.  According to the University of Pittsburgh Medical Center, approximately ten percent of all athletes involved in contact sports, such as football, hockey, and soccer, suffer a concussion each year.  In high school sports, there are 60,000 concussions each year with 63% occurring in football.  Even in contact sports, some concussions can be prevented by teaching proper playing and tackling techniques and by wearing proper headgear.  Symptoms of concussion are not always definite and knowing when it is safe for an athlete to return to play is not always clear.  Severe concussions display obvious symptoms and removal from participation is obvious. However, the athlete with a mild concussion can display symptoms that are less clear. There are serious repercussions of early return following even a mild concussion due to the long term effects of multiple mild concussions. The recognition and management of concussion in athletes can be difficult for a number of reasons:

Athletes who have experienced a concussion can display a wide variety of symptoms.  Classic symptoms of loss of consciousness, confusion, memory loss, dizziness and/or balance problems may be present in some athletes with mild concussion, while others may not show obvious signs that a concussion has occurred.

Post-concussion symptoms can be quite subtle and may go unnoticed by the athlete, team medical staff, or coaches.
Many coaches and other team personnel may have limited training in recognizing signs of concussion and therefore may not accurately diagnose the injury when it has occurred.

Many players may be reluctant to report concussive symptoms because of fear that they will be removed from the game, or that it may jeopardize their status on the team or their careers.

Methods and tools used to detect concussion and help make accurate return-to-play decisions are inadequate. Traditional neurological and radiological procedures, such as CT and MRI, although invaluable in discerning more serious head injuries, are not consistently useful in evaluating the effects of mild head injuries.

Recovery and safe return-to-play

Allowing enough healing and recovery time following a concussion is crucial in preventing further damage.  Research suggests that the effects of repeated concussion are cumulative.  Most athletes who experience an initial concussion can recover completely as long as they are not returned to contact sports too soon.  Following a concussion, there is a period of change in brain function that may last anywhere from 24 hours to 10 days.  During this time, the brain may be vulnerable to more severe and permanent injury.  If the athlete sustains a second concussion during this time period, the risk of permanent brain injury increases. The long term symptoms resulting from multiple concussions may include chronic headaches, sleep difficulties, dizziness, cognitive impairment and personality changes.

To assist in accurate diagnosis and safe return to sport, The University of Pittsburgh Sports Medicine Center developed a special computer program. The program uses diagnostic tools developed at the school such as the ImPact (immediate post-concussion assessment and cognitive testing). This computerized software can help to make safe return-to-play decisions by comparing an athlete’s brain function before and after a suspected concussion. The ImPact is a sophisticated, though easy to use, soft-ware program that has been specifically developed to help clinicians objectively evaluate recovery following concussion. The test is a 20-minute computerized test battery that can be administered in the preseason for a baseline and post-injury to track a concussion.  The ImPact allows for proper determination that the athlete has fully recovered from a concussion, thus ensuring a safe return to play.  Hopefully, this program will become affordable and accessible to small communities such as ours in the near future. For more information, call the University of Pittsburgh Sports Medicine Concussion Program at 412-432-3668.

Visit your doctor regularly and listen to your body.
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!”
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email:

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an affiliated faculty member at the University of  Scranton, PT Dept.