MTBI Evaluation Requires Serial Follow-ups
MTBI Evaluation Requires Serial Follow-ups for More than Just Athletes
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The “MTBI evaluation” (evaluation to rule out a mild traumatic brain injury) must include a serial followup for all individuals, not just athletes. At a previous page, I discussed the significance of the 1992 ACRM definition of MTBI. Equally important was the 1997 promulgation by the American Academy of Neurology of its Practice Parameter: The Management of Concussion in Sports. While there were certain similar guidelines before and dozens since, putting the weight of the American Academy of Neurologists woke up a lot of physicians to the proper methodology for concussion diagnosis, regardless of what might be written about the necessity of loss of consciousness in traditional authorities such as Adams and Victor and the DSM-IV.
Much of the impetus for this break-through in the treatment of sport concussion came out of concern for what is called the “second impact syndrome”. Second impact syndrome can occur when the second concussion occurs while the brain is still reeling from the first. What is believed to occur is a dysregulation of the nervous system’s control of blood pressure to the brain, resulting in catastrophic increases in intracranial pressure. The result of second impact syndrome can be profound additional injury or death.
Second impact syndrome continues to be a strong catalyst for change in return to play rules with the Lystedt law which prohibits any return to play after concussion now law in several states and being considered in many others. Zachery Lystedt was a high school football player in Washington who suffered a mild concussion early in a game but continued to play. Near the end of the game he suffered another concussion, which resulted in a severe brain injury. His injury became the impetus for a law in his home state of Washington prohibiting any return to play of a scholastic athlete after a concussion.
With the promulgation of the AAN Practice Parameter in 1997, return to play issues with respect to concussion became mainstream. The AAN’s guidelines most important element was its requirement that if an athlete continued to be symptomatic of concussion for more than 15 minutes after the injury, that athlete was not to return to play until a full seven days after the symptoms have cleared.
When the AAN guidelines are applied properly there is a 15 minute post-injury evaluation to determine whether this concussion or “ding” was serious enough to require further follow-ups. An injured player is not supposed to return for at least 15 minutes. At 15 minutes, if they continue to be symptomatic, they are not to return to play in that game and not until the expiration of 7 days from the date they cease to be symptomatic.
While the 15 minute rule is not quite good enough it is important that an athlete is at least required to wait that long before he or she returns. As brain injury is a “process not an event” that can take 72 hours to manifest itself, the 15 minute rule isn’t perfect. While the 15 minutes is a compromise, that generally protects the player. While there are exceptions, the concussion that is completely asymptomatic at 15 minutes is probably not going to be serious.
But keep in mind, that Natasha Richardson could likely have passed a superficial orientation test at 15 minutes and she died before they could get her to a hospital. Also with non-professional sports, there is a strong movement to not allow any return to play.
The truly important part of guidelines is the “no play for seven days” if the concussion continues to be symptomatic at 15 minutes. Thus if there is symptomotology of brain injury at 15 minutes, the professional team’s medical staff will do follow-up testing each day to determine whether the athlete continues to be symptomatic. It is this followup testing that is missing in the non-sport concussion setting. Typically, the person being discharged, whether a diagnosis of concussion has been made, is told to followup with his or her family doctor. That just isn’t good enough. What more we need to require is discussed next.