What do Markieff Morris, Giannis Antetokounmpo, Andre Drummond, Dwayne Wade, and Nerlens Noel have in common? If you said they all play basketball, you would be right, but they have, also, all entered and cleared the NBA’s Concussion Protocol this season. Around here, we love the Oklahoma City Thunder; so when Nerlens Noel went out earlier this year, we wondered what the NBA’s Concussion Protocol1 consisted of. Our physical therapists treat post-concussion symptoms all the time, so we are acutely aware of the need for vestibular rehabilitation as part of a concussion management program.
Unless you have just woken up, a la Rip Van Winkle, you’ve no doubt heard about concussions, chronic traumatic encephalopathy, and second impact syndrome. No longer is it appropriate to consider a concussion a “little ding” and send players back into the game. The need for concussion management is key, but we have to agree on what we say when we talk about concussions. Concussions vary in the intensity and duration of symptoms, so when we talk about a concussion we are talking about a collection of clinical symptoms that must be diagnosed by a medical professional. And until recently, there wasn’t a consensus definition of a concussion.
How does the NBA define a concussion?
They have defined a concussion in accordance with International Concussion in Sport Group (CISG), which is a team of experts in identifying and treating concussions. This is a great start, the CISG has done a thorough job of defining what we are talking about when we say “concussion.” Prior to the CISG delivering its Consensus Statement on Concussion in Sport2, there was no consensus on what should qualify as a concussion. Here is what the CISG considers a concussion:
Sport related concussion (SRC) is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:
- SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
- SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
- SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
- SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.
The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc) or other comorbidities (eg, psychological factors or coexisting medical conditions).
What happens before a concussion?
Now that everyone knows what we are talking about, the NBA has set-up concussion education for players, coaches, and medical staff. The annual education examines a variety of concussion related topics including why concussions happen, what they look like, how to manage them, and when complications arise. It is clear that the NBA considers the who of concussion management to be everyone involved, a stance that is leading the charge in protecting players’ long-term health.
The NBA also does annual baseline testing. At this point in time, baseline testing is best practice in pro-actively managing concussion symptoms. When you are dealing with professional athletes, comparing to a standardized population sample might be possible, but it is hard to compare someone on the tail end of a sample to the group mean. When you can compare current neurologic and cognitive performance to oneself there is no question about whether the athlete in question has a decrement. When it comes to head injury, I for one am glad that the NBA isn’t leaving this possible margin of error to chance. Baseline testing will only serve as a comparison to make sure that the player does not return to action too soon.
What happens when a Player sustains a blow to the head?
The first thing that occurs following a blow to the head is the Player’s removal from participation. The player will undergo an evaluation in a quiet, distraction-free environment. This is where baseline testing is key. Even immediately after suffering a concussion it is possible that some players are going to do better on the neurologic screening than population means, but they aren’t likely to do better than themselves prior to sustaining the injury.
If there is no diagnosis of a concussion, the player will be evaluated a second time no later than 24 hours after the initial concussion evaluation. If no concussion is diagnosed after 24 hours, then theoretically the Player could return to active participation and would simply be monitored for the development of any additional signs or symptoms.
Regardless of when (initial or follow-up evaluation), if a Player is diagnosed with a concussion, they are prohibited from returning to participation. He cannot play. The Player will be given 24-48 hours of cognitive and physical rest. This is consistent with the CISG consensus statement, which acknowledges that extended rest in all circumstances may not be warranted. The rest period is determined by the Player and team physician together. If exertion does not worsen the Player’s symptoms, the Player may progressively increase exertion.
When can the Player return to participation?
This is what fans want to know, and unfortunately for them, there is no exact timeline. In order to return to participation, the Player must pass neurologic testing during progressively increased steps of exertion and remain symptom free. Passing all of the steps in the Return-to-Participation Exertion process are not a free pass to return to participation. The player must still be cleared by the team physician after discussing with Dr. Jeffrey Kutcher, the NBA’s Director of the NBA Concussion Program and a member of the CISG.
Where do we go from here?
The NBA’s Concussion Protocol continues to evolve each season, and it should. We continue to learn more about how to best screen for an manage concussions. One area the Concussion Protocol might be lacking is in best practice of concussion treatment. At this point in time, the NBA seems to leave that up to individual teams rather than have a prescriptive process. With the NBA leading the charge in professional sports on the identification and management of concussions, we at FYZICAL would love to see the next step in the process be the active management not only of clearing the player but treating the symptoms associated with concussion.
-FYZICAL Therapy & Balance Centers of Oklahoma City
- https://ak-static.cms.nba.com/wp-content/uploads/sites/4/2018/10/2018-19-Concussion-Program-Summary.pdf
- https://bjsm.bmj.com/content/51/11/838