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New concussion assessment regimen helps determine return to play for hockey players

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Barry Willer

Investigators at the University at Buffalo have developed a reliable graded exercise test for concussions that could assist team physicians in making decisions about a player’s readiness to return to ice, according to a study published in the Clinical Journal of Sports Medicine.

“Premature return to a sport after concussion greatly increases the risk of a follow-up concussion, with more devastating results than the first concussion,” lead study author Barry Willer, PhD, stated in a University at Buffalo release. “We believe this approach could change the way professional and amateur sports team physicians make decisions about concussion recovery.”

Reliability of testing

The researchers aimed to test for both retest reliability (RTR) and interrater reliability (IRR). For RTR, the team examined 21 refractory concussed patients — 11 athletes, 10 non-athletes — and 10 healthy subjects. For IRR, the study utilized 32 raters who, according to the abstract, represented “a variety of health care disciplines.”

The Balke protocol treadmill test was used to the point of symptom exacerbation both before and after 2 weeks to 3 weeks for the purpose of testing RTR. For IRR, the abstract noted, video recordings of actors during the treadmill test were viewed by raters blinded to condition. The main reported outcome measures for RTR included agreement of tests for maximal heart rate, systolic blood pressure, diastolic blood pressure, and perceived exertion rating. The presence or absence of symptom exacerbation — as well as the symptom exacerbation heart rate — were used as the outcome measures for IRR.

The researchers reported that raters were able to achieve 99% sensitivity for identifying actors with symptom exacerbation and 89% specificity in terms of ruling out concussion symptoms. Overall, the raters agreed on 304 of 320 observations — an accuracy of 95%. Intraclass correlation coefficient for symptom exacerbation heart rate was reported at 0.90. The treadmill test, the authors reported, had satisfactory RTR for maximum heart rate, but not for systolic blood pressure, diastolic blood pressure, or rating of perceived exertion.

“We obtained the same results regardless of who made the assessment,” Willer stated in the release. “This controlled exercise assessment procedure is the only approach to determining readiness to return to play that has proven to be reliable. Another advantage of this assessment procedure is that it can be carried out by any physician, physical therapist or athletic trainer with a minimum of training, as long as they have access to a treadmill and a heart rate monitor.”

Reference:

• Leddy JJ, Baker JG, Kozlowski K, et al. Reliability of a graded exercise test for assessing recovery from concussion. Clin J Sport Med. March 2011;21;2:89-94. doi: 10.1097/JSM.0b013e3181fdc721
• Disclosure: The research was supported by the Robert Rich Family Foundation, as well as the Buffalo Sabres Foundation.
• www.buffalo.edu

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