Return-to-Play Test?


Perhaps.  University of Buffalo doctors and researchers believe that they may have a tool that can provide definitive answers and take the “chance” out of the impending second injury.  John J. Leddy, MD, Karl Kozlowski, PhD and Barry Willer, PhD are authors of a study aimed at just doing that;

University at Buffalo researchers have developed a test to determine when it’s safe for athletes to return to play after a concussion.

Currently no standardized method exists to assess when the time is right. It is usually a judgment call made by team physicians.

“We believe this new approach could change the way professional and amateur sports team physicians make decisions about concussion recovery.”
Barry Willer, PhD
professor of psychiatry and rehabilitation medicine and senior author on the paper

The treadmill test devised by UB concussion specialists in the Department of Orthopedics could change that by providing a systematic approach to evaluate readiness.

“In the past, how a team physician and trainer made this decision was left to chance,” says Barry Willer, PhD, professor of psychiatry and rehabilitation medicine.

Willer is senior author of a paper titled Reliability of a Graded Exercise Test for Assessing Recovery from Concussion, published in the Clinical Journal of Sport Medicine.

Using the Balke standardized treadmill test the subjects were taken to either symptom exacerbation or perceived exhaustion.  Starting at 0% grade and 3.3 mph (static speed) the researchers looked at heart rate, blood pressure, perceived exertion, and symptom/health status.  The grade was increased 2% after 1 minute then changed 1% each minute thereafter.  Showing very high values of retest reliability and interrater reliability proposed the following in the published article;

We propose that the response to incremental (provocative) exercise testing can help with the RTP decision. Provocative exercise testing should only be performed, however, in patients whose rest symptoms have resolved and for whom a determination is being made as to fitness to return to sport or activity4 because experimental animal data show that premature voluntary exercise within the first week after concussion impairs cognitive performance,18 an observation corroborated by some human data.19 Provocative exercise testing should therefore be administered at the appropriate time after concussion.

This study represents an attempt to standardize the process of provocative testing by determining the reproducibility of a treadmill test that challenges the physiology of patients with concussion. The primary limitation of the study is that there is no established “gold standard” for the diagnosis of concussion.

Later in the discussion of the results the authors used a “point-counter-point” example of a return to play recommendations based upon this new protocol;

The clinical use of a standardized and reliable provocative treadmill exercise test is illustrated by the example of a high school athlete who has sustained his second concussion within the previous year and who presents to your office for clearance to resume contact sport. His symptoms were of greater severity and of longer duration after the most recent concussion. He reports that after 12 days of cognitive and physical rest, he is asymptomatic at rest and he has reached baseline performance on a computerized NP test. His mother confirms that he has not reported any symptoms, and she thinks he is back to normal, but she wants to know if he is ready to play in the next game, which is in 5 days. Using the Balke protocol on your office treadmill, the athlete exercises at progressively increasing exercise intensities to exhaustion without symptom exacerbation. You conclude, and inform the athlete and his mother, that he is physiologically recovered and can safely RTP. Conversely, if the athlete developed signs or symptoms that stopped the test before peak exertion, you have objective information that he is not physiologically ready and will need more recovery time.

This is another good tool to take a look at, anything that can give a more clear picture of readiness after a concussion would be helpful not only to the clinician but the athlete, parent and coach.

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