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Return to Play Following Sports-RelatedMild Traumatic Brain Injury: The Role forNeuropsychologyRuben J. Echemendia & Robert C. CantuPublished online: 07 Jun 2010.

To cite this article: Ruben J. Echemendia & Robert C. Cantu (2003) Return to Play Following Sports-RelatedMild Traumatic Brain Injury: The Role for Neuropsychology, Applied Neuropsychology, 10:1, 48-55, DOI: 10.1207/S15324826AN1001_7

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Applied Neuropsychology Copyright 2003 by2003, Vol. 10, No. 1, 48–55 Lawrence Erlbaum Associates, Inc.

Return to Play Following Sports-Related Mild Traumatic Brain Injury:The Role for Neuropsychology

Ruben J. EchemendiaDepartment of Psychology, The Pennsylvania State University, University Park, Pennsylvania, USA

Robert C. CantuDivision of Neurosurgery, Emerson Hospital, Concord, Massachusetts, USA

Cerebral concussions frequently occur at all levels of athletic competition. The effects fromthese concussions can be transient or may lead to chronic, debilitating symptoms. A growingliterature has established that neuropsychological tests are useful in detecting the subtle neu-rocognitive changes that occur following concussions. The identification of these deficits andsubsequent recovery of function can be important components in making return-to-play(RTP) decisions. This article describes the emergence of neuropsychology in sports medicine,discusses the context in which RTP decisions are made, outlines factors that are important toRTP decisions, and presents a model that views the RTP decision as a dynamic risk-benefitanalysis that involves complex interactions among variables. It is argued that neuropsy-chology has a unique, but not exclusive, role in the decision making process. Implications forfuture research are discussed.

Key Words: cerebral concussions, return to play, risk-benefit analysis, neuropsychology

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Interest in the area of sports neuropsychology hasgrown significantly over the past decade. An importantreason for this interest has been the development ofprograms specifically geared toward the neuropsycho-logical assessment of sport-related mild traumaticbrain injury (MTBI), also known as cerebral concus-sion. Epidemiological data provide compelling evi-dence that cerebral concussions are common withincontact sports at all levels of play (Powell & Barber-Foss, 1999). It has also become apparent that sportsoften thought to be noncontact (e.g., basketball) haveathletes who sustain concussions at a relatively highrate (Putukian & Echemendia, 1996). Although con-cussions have traditionally been thought of as mild“dings” to the head with no discernable sequelae, wenow know that the symptoms of concussion can rangefrom highly transient annoyances to debilitating post-concussion syndrome or even death.

The combination of high prevalence rates and possi-ble severity of the injury has captured the attention of

sports medicine personnel, coaches, players, and themedia. With this attention has arrived an interest in thereliable and valid assessment of MTBI. For example,the National Institute of Medicine, part of the NationalAcademies of Science, recently sponsored a conferencethat examined the issue of heading in soccer players (In-stitute of Medicine, 2002). The primary focus of theconference was to examine neuropsychological evi-dence regarding repeated purposeful heading of the soc-cer ball. Although the panel concluded that there was noconvincing evidence to date that heading leads to long-term neurocognitive dysfunction, they did call attentionto the fact that concussions occur at a relatively high ratein soccer because of head-to-head, head-to-foot, andhead-to-equipment (e.g., goal posts) contact.

Neuropsychology has been thrust into a unique rolein the assessment of sports-related concussion. Thepathophysiology of MTBI is such that it is largely in-visible to traditional radiologic techniques (e.g., com-puted tomography, magnetic resonance imaging).Without the ability to detect the injury objectively,sports medicine physicians were forced to evaluate theinjury through clinical means that were thought to bethe best practices in the field. A large number of sever-ity rating (grading) scales were developed that relied

Requests for reprints should be sent to Ruben J. Echemedia,119 S. Burrowes St., Suite 602, State College, PA 16801, USA. E-mail: RJE2@psu.edu

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entirely on symptom report by athletes or direct obser-vation by on-site personnel. There is no consensus inthe field as to which grading scale should be used.These grading scales (e.g. Cantu, 1998; Colorado Med-ical Society, 1991; Quality Standards Subcommittee,American Academy of Neurology, 1997) divide sever-ity into three grades that correspond to mild (I), moder-ate (II), and severe (III) concussions. Sets of guidelinesfor return-to-play (RTP) decisions were developed andcorrespond to each of these grades. For example, aplayer who sustains a Grade II concussion (no loss ofconsciousness, posttraumatic amnesia) under the Col-orado Medical Society’s grading system would be al-lowed to RTP after he or she was asymptomatic at restand after exertion for 1 week. Although these gradingsystems and guidelines raise the awareness that cere-bral concussions must be treated with caution and pro-vide some uniformity to the management of concus-sion, they are not based on empirical evidence. Further,they rely solely on the self-report of athletes who areoftentimes motivated to underreport their symptoms sothat they can return to competition prematurely. This isworrisome in light of Echemendia, Putukian, Mackin,Julian, and Shoss’s (2001) findings that athletes’ reportof symptoms did not differentiate between concussedathletes and noninjured controls 48 hr following con-cussion, despite very significant differences in neu-rocognitive functioning between the two groups.

Taken together, these factors help set the stage forneuropsychology’s emergence in sports medicine.Neuropsychological tests and approaches have longbeen used to assess neurocognitive changes followingMTBI. At the University of Virginia, Barth et al.(1989) first introduced neuropsychology to sports.They were the first to use the now common paradigmof testing players at baseline and then testing the play-ers serially postinjury. Barth et al.’s original datademonstrated that neuropsychological tests were ableto detect neurocognitive changes following concussionand that these changes generally returned to baselinewithin 10 days of injury. These findings have beenreplicated across many studies, but it is beyond thescope of this article to review them. The interestedreader is referred to Echemendia and Julian (2001) andErlanger, Kutner, Barth, and Barnes (1999).

The RTP Decision

The RTP decision process is unique in neuropsy-chological practice because it requires that the neu-ropsychologist identify the point at which an injured

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athlete has recovered from the effects of a concussionand is able to return to a situation in which additionalinjury may occur. Preventing athletes from returning tosport for unnecessarily long periods of time may havesignificant impact on the athlete’s career, financial via-bility, and psychological functioning. However, theimportance of the RTP decision rests on the possibleramifications of a premature decision. Animal andhuman data have made it clear that a variety of neuro-chemical and structural changes occur in the brain fol-lowing concussion. These data suggest that a neuro-chemical cascade begins within minutes of concussionand often lasts several days following concussion.During this period, neurons that have not been de-stroyed remain alive but in a vulnerable state. Thesecells are uniquely susceptible to minor changes incerebral blood flow, increases in intracranial pressure,and, especially, anoxia. Animal studies have shownthat during this period of vulnerability, a minor reduc-tion in cerebral blood flow that would normally be in-consequential now produces extensive neuronal cellloss (Jenkins et al., 1989; Lee, Lifshitz, Hovda, &Becker, 1955; Lifshitz et al., 1955; Sutton, Hovda,Adelson, Benzel, & Becker, 1994).

The neurochemical and structural cascade has paral-lels in neurocognitive functioning. Several studies havedocumented that neurocognitive changes can exist up to10 days following concussion (Barth et al., 1983;Collins et al., 1999). Echemendia et al. (2001) foundthat neuropsychological test scores, particularly with re-spect to verbal learning and memory, begin a process ofdecline that begins as early as 2 hr postconcussion andmaximizes at 48 hr postinjury. Some deficits were foundto exist up to 1 week following injury, but controls andconcussed athletes were indistinguishable from eachother at 1 month following concussion.

In light of the vulnerabilities noted previously andthe possible catastrophic effects of second impact syn-drome (Cantu & Voy, 1995; Kelly et al., 1991; Saunders& Harbaugh, 1984), it is clear that the RTP decisionmust reliably determine when the effects of the concus-sion have ended and the player is safe to resume com-petition. This is the key role for neuropsychology insports medicine. Although useful in detecting the sever-ity of concussion, current neuropsychological tests arenot very practical in the diagnosis of concussion insports. Diagnosis can be accomplished efficientlythrough sideline examinations conducted by well-trained medical personnel. Neuropsychological testsprove their usefulness in detecting the neurocognitiveeffects of the concussion and, more importantly, whenthose neurocognitive changes have returned to baseline.

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The RTP Decision in Context

The RTP decision is complex and dynamic and in-volves many factors. It also occurs within a contextthat is unfamiliar to neuropsychologists. In this article,we describe the context in which the RTP is made andthen elaborate a RTP model developed by Echemendiaand Cantu (in press). Any neuropsychologist interestedin working in this area needs to develop a good work-ing understanding of this complex arena.

Sports teams exist within a culture in which thereare multiple competing demands and a variety of inter-ested parties that often have competing agendas. Manyindividuals may have impact on the RTP decision. Atthe professional level, there are the players, the man-agement, coaching staff, agents, attorneys, media, fam-ily, friends, advertising contracts, and medical staff,among others. College players contend with the play-ers on their team, the team hierarchy, the college hier-archy, medical staff, professors, their parents, girl-friends and boyfriends, scouts for professional teams,potential agents, and attorneys. At the high schoollevel, coaches, teammates, parents, girlfriends andboyfriends, teachers, and college scouts may influenceplayers. These individuals and their various viewpointsalso interact with the level of play. As the level of playbecomes more elite, the pressures intensify across allfronts. It is important to recognize the complexity ofthe context in which players operate because many ofthese individuals can potentially influence the RTP de-cision. Although it may be argued that RTP decisionsshould only involve medical factors, this perspective islikely unrealistic. In our view the RTP decision is acomplex interaction of many factors with the decisionmaker constantly involved in a risk-benefit evaluation.It is also important to underscore that sports are com-petitive and frequently emotional, and decisions, in-cluding RTP decisions, are not solely based on deduc-tive reasoning or logic.

The team physician generally holds the ultimate re-sponsibility for the RTP decision. It is their responsi-bility to gather all of the necessary information and usethat information to make the RTP decision. There ismarked variability among physicians with respect totheir involvement with the team, awareness of sportsmedicine, and knowledge of sport-related concussion.Some team physicians (e.g., those with professionalteams and elite college teams) know the players well,travel with the teams, and are often specialty trained insports medicine or orthopedics. At the other end of the spectrum are high school teams that rely on eachplayer’s family physician or an emergency room physi-

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cian to make the RTP decision. There is marked vari-ability among these physicians regarding their experi-ence with sports-related concussion.

Athletic trainers have often been described as theeyes and ears of the team physician. They are the mem-bers of the medical staff that work most closely withthe players. They are an invaluable source of informa-tion regarding the players and the nature of their in-juries. The athletic trainer is usually the first on thescene to evaluate a player, and they generally have athorough understanding of sports-related concussion.Unfortunately, not all teams have access to athletictrainers. In high schools there may be only one full-time athletic trainer for all of the sports teams. Collegeteams often do not travel with athletic trainers andwhen they do it is often the case that student trainers dothe traveling. Athletic trainers are often quite busy be-fore, during, and after athletic competition. Given theirworkload, it is easy for them to miss the sometimessubtle symptoms of concussion unless the player di-rectly reports symptoms.

All teams have coaches and coaches are criticalcomponents in the management of concussion andRTP. Coaches vary in their relationships with medicalstaff. Some coaches view the medical staff as an inte-gral part of the team, whereas others view the medicalstaff as a necessary evil. The coach sets the tone for ateam both on and off the field. This is particularly truefor the issue of sports concussion. If the coach recog-nizes the importance of careful management of con-cussions, the players will also appreciate the impor-tance of the injury and more accurately report theirsymptoms. If, on the other hand, a coach does not be-lieve in concussions, then detection and managementof concussions becomes a very difficult process be-cause players are encouraged to play through theirsymptoms and not report symptoms to medical staff. Itis also important to recognize that in most youth sportsthe coach is the person on the field who is evaluatingthe severity of injuries. Since many coaches have min-imal or no understanding of concussions it is likelythat many children are receiving concussions and arenot being evaluated or treated.

The team may also be a major influence on the RTPdecision. For example, if a high-profile player is side-lined because of a concussion, the team may betempted to pressure the medical staff into prematureRTP, particularly if there is a big game at stake. Agame of little or no consequence may elicit a very dif-ferent response from the team. Teammates are also im-portant factors in the identification and management ofconcussion. If players are educated to the signs and

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symptoms of concussion and they recognize the im-portance of the injury, they can be very helpful in de-tecting players who are showing the signs and symp-toms of concussion. The players can accurately reportif a fellow player is acting “goofy” or they are notbeing themselves. They know when teammates aremissing plays or otherwise behaving erratically. Team-mates are also quite helpful in alerting medical staff tosituations where a concussed player is minimizingsymptoms in order to return to competition.

Families play an important role in the RTP decisionbecause of the integral role that they play in the lives ofathletes. The family of a high school athlete who hassustained two concussions in a season may want theirchild to stop playing the sport because of fear of cata-strophic injury. Or, parents may become angry withmedical staff if their child is held out of competitionbecause of a concussion. Often, they provide somevariant of “he’s tough, he can play” or “there’s nothingwrong with her . . . I had a lot of worse injuries and Icontinued to play.”

The player is also a key figure in the RTP decision.He or she is the one most directly affected by the RTPdecision. It is important to speak with the player and gethis or her views on returning to sport. Usually, athletesare highly motivated to return to play and consequentlymay minimize their symptoms. It is important to knowwhether the athlete will tend to minimize or, in somecases, exaggerate their symptoms. It is also critical todiscuss with the athlete if they feel ready to return tocompetition. It is not unusual for athletes with concus-sions to become frightened of returning to play. Theygenerally will not voice this fear unless asked directly.

The Role of Neuropsychology

The neuropsychologist does not usually make theRTP decision. In most instances, the neuropsycholo-gist is a consultant to the team physician, and neu-ropsychological data are an important component ofthe RTP decision. Neuropsychologists generally be-come involved with concussed athletes in one of twoways: as part of an established neuropsychologicaltesting program, where there exists baseline testingand a protocol for postinjury testing, or as a referralfrom a physician for a player who has had a concus-sion, but the player is unknown to the neuropsycholo-gist and no baseline data exist. In both cases, the ulti-mate questions remain the same. Is the player sufferingany neurocognitive sequelae from the concussion, canhe or she return to play? The answer to these questions

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is sometimes clear-cut. For example, the player dataare significantly below baseline, the player is sympto-matic, and he or she does not feel right. There wouldbe general consensus that this player should not be returned to competition. The more typical scenario involves conflicting information. For example, theplayer is asymptomatic at rest and on exertion, yet the neuropsychological data are below baseline. Or,the neuropsychological data are only marginally belowbaseline. It is beyond the scope of this article to fullyevaluate these issues. Since sports neuropsychology isa young field, many important basic questions remainto be answered by empirical studies. Do players needto reach baseline levels of functioning or should theyactually exceed baseline levels because of practice effects? How far above or below baseline should aplayer perform before being allowed to return to play?How should previous concussions be included in thedecision-making process? How should qualitative,process data be evaluated?

A relatively infrequent role for neuropsychologistsincludes evaluating players on the sideline. In this con-text, neuropsychologists are available to assist theteam physician or athletic trainer with the RTP deci-sion. In some cases it will be up to the team neuropsy-chologist to make the RTP decision. In these situationsit is important that the neuropsychologist knows theplayers and has specialized experience working withsports teams. A thorough sideline assessment will needto be conducted. It should include assessment of motorcoordination, orientation, attention and concentration,memory, information processing speed, and so on.Systematic approaches have been developed for side-line assessments (see Lovell, Echemendia, & Burke, inpress; McCrea et al., 1998).

A Dynamic Model for RTP

Thus far, we have described a brief historical per-spective on neuropsychology’s role in sports, the vari-ous individuals who may play a role in the RTP deci-sion, and the role of the neuropsychologist as aconsultant in the RTP decision. How do these factorscome together and how are they integrated in the RTPdecision? We have proposed a dynamic model that at-tempts to capture some of the important elements inthis process. Variables of interest may have direct in-fluences on the RTP decision (e.g., whether a playerhas a positive magnetic resonance imaging finding orremains symptomatic), or it may have an indirect in-fluence (e.g., affecting an upcoming big game). These

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variables may be grouped into the following factors:medical factors, specific concussion factors, playerfactors, team factors, and extraneous factors.

Medical factors have a direct influence on the RTPdecision. These factors include any positive findingson neuroimaging, any abnormalities detected on com-prehensive physical and neurological examination, andany player report of symptoms at rest or during exer-tion. The player should not be returned to sport untileach of these findings has resolved completely. In thecase of neuroimaging, it is possible that a structural ab-normality is unexpectedly detected that may place theplayer at risk for brain injury. These findings need tobe carefully evaluated since RTP may not be advisable.

Concussion factors include those variables that aredirectly related to the concussion(s) being assessed.The severity of the injury is the first factor to be evalu-ated. Even though there is little agreement on the grad-ing systems for concussion, they can be helpful in as-sessing the severity of the injury. The absolutenumbers of symptoms that a player reports as well theintensity of those symptoms are important factors toevaluate. In general, the more symptoms that a playerreports, the greater the likelihood that the concussionis more severe. The level, type, and extent of any am-nesia should be evaluated. The more dense the amnesiaand the longer it lasts, the more severe the concussion.

Loss of consciousness (LOC) or coma has beenused as a marker of concussion severity. A significantliterature exists that relates length of coma to outcomeamong patients with traumatic brain injuries (TBI).Following the TBI literature, most of the concussionsgrading systems regard any LOC as the most serioustype of concussion. However, the LOC that is seen onthe sports field is usually momentary and rarely lastsmore than 2 min. Lovell, Iverson, Collins, McKeag,and Maroon (1999) looked at the neuropsychologicaltest performance of patients admitted to the emergencydepartment with MTBI and found that short durationLOC was not predictive of concussion severity. Simi-larly, Erlanger and Kroger (2001) found no relation-ship between Grade III concussion and either neu-ropsychological test performance or duration ofpostconcussion symptoms. These findings have ledCantu to revise his concussion grading system to relymore on symptom duration and posttraumatic amnesia(Echemendia & Cantu, in press).

Concussion history should be carefully evaluated forany player sustaining concussion. The absolute numberof concussions, their temporal relationship and durationof symptoms are all thought to be important factors inevaluating the effects of concussion. Collins et al.

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(1999) found that football players with two or moreconcussions did worse on baseline neuropsychologicaltesting than those with one concussion or less. Thisstudy had a limited sample size and only one measureexhibited this relationship. In contrast, Macciocchi,Barth, Alves, Littlefield, and Jane (2001) found no rela-tionship between the number of concussions and neu-ropsychological test data. Although there are no consis-tent data within sports that support the contention thatmultiple concussions lead to long-term neurocognitivedeficits, there exists ample clinical evidence to suggestthat greater care should be exercised with players whohave experienced multiple concussions.

In light of the animal findings regarding the brain’svulnerability following a concussion, the temporal se-quence of concussions appears to be important. Themore closely spaced the concussions, the greater cau-tion should be exercised. Also of importance are thelength of symptom duration and the nature of the blowthat creates the concussion. The longer symptoms last,the more severe the concussion is thought to be. Thenature of the blow is important since it has been ob-served clinically that some players with multiple con-cussions exhibit symptoms with increasingly lighterblows. Whereas a very significant and direct blow tothe head may be necessary to create the initial concus-sion, a subsequent concussion may occur with a lesspowerful and often indirect blow (e.g., to the posteriorthorax). These cases should be carefully examined be-cause they may signal the need to terminate a player’scareer.

Neuropsychological factors provide important, di-rect information to be used in the RTP decision. Asnoted earlier, neuropsychology is a newcomer to thesports medicine team, and there are many importantquestions that remain unanswered. However, theweight of the data that has been assembled thus farclearly suggests that neuropsychological tests are capa-ble of detecting neurocognitive deficits as soon as 2 hrfollowing cerebral concussion (Echemendia & Julian,2001). These neurocognitive deficits may or may notcoincide with player reported symptoms. Given thepropensity for players to minimize their symptoms toreturn to competition, and the likelihood that they areoften unaware of the cognitive deficits that they mayexperience, it seems prudent to keep an athlete fromathletic competition until neuropsychological data areinterpreted as having returned to baseline.

Player factors are often overlooked in the RTP deci-sion, even though the player is the most important ele-ment in the decision. It is our experience that the vastmajority of medical professionals who have been in-

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volved in RTP decisions agree that evaluating a playerafter concussions is easier, and likely more valid, whenyou know the player. Knowledge of the player and hisor her personality is crucial in determining whether theplayer is exhibiting odd behavior or personalitychanges. The player’s personality is also important indetermining the aggressiveness of their play, their ten-dency to minimize symptoms, their willingness to fol-low advice, how they will respond to the concussion,and whether the player can be trusted to report anyreemergence of symptoms. If the evaluating personneldo not have firsthand knowledge of the player it is im-portant that they seek out this information fromsources close to the player.

The player should have a voice in the RTP decision.This does not necessarily mean that the player willagree with the decision. Very often he or she does notagree. But involving the player in the decision helpsthe player understand the factors that were evaluated inthe decision and generally will lead to greater accep-tance of the decision by the player.

The player’s skill level, career goals, and use of propertechniques are important considerations, particularlyamong younger athletes. Some athletes regard sports as ahobby that they enjoy and helps structure their free time.For others, sports are a prominent component of theiridentity. Career aspirations may need to be evaluatedeven though they may have indirect influence in the deci-sion. Since any RTP decision is an assessment of risk andbenefit, a physician who has a player with borderlinedata may be more inclined to allow an elite athlete withprofessional aspirations to return to sport than an athletewho does not have career goals in sports.

Team factors may also have indirect relevance to theRTP decision. The level of play (recreational vs. com-petitive elite or professional), team standing, team cul-ture, importance of the game, the player’s position, andthe player’s standing on the depth chart may all need tobe evaluated in the RTP decision. These factors primar-ily come into consideration in the presence of equivo-cal data. If a player is symptomatic—has clear neu-rocognitive changes on testing or positive physicalexamination, or neuroimaging findings—the playershould not be returned to play until there is return tonormal functioning. However, if RTP is unclear, it ismuch easier to withhold an athlete from competing in aregular game than it is to keep them out of a nationalchampionship. Because less is known about the effectsof concussion on younger players, it is often advisableto take a much more cautious stance with younger play-ers than it is with older, more highly trained athletes.Sometimes the player’s position is also important. For

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example, a goalie in ice hockey is much less likely tosustain a concussion when compared to a forward.

Extraneous factors may also impact the RTP deci-sion. Some physicians or coaches may consider vari-ables such as field condition, natural versus artificialturf, traditional versus seamless glass (hockey), oppos-ing team characteristics and fans (among others) inmaking the RTP decision. Some situations or condi-tions may increase the likelihood of reinjury.

Figure 1 depicts the dynamic interactions amongthese factors. As can be seen, some variables have di-rect and important influences on the RTP decision.Solid, bold lines depict these relationships. The num-ber of lines suggests the strength of influence. For ex-ample, medical factors have a very strong and directinfluence on the RTP decision. Neuropsychologicalfactors also have a direct relationship to the RTP deci-sion yet they are not as strong as the medical factors.Some factors have relationships among themselves aswell as being related to the RTP decision. Neuropsy-chological factors and concussion factors are related toeach other and both have direct effects on RTP. Playerfactors and team factors are bidirectional and have in-direct (dotted lines) impact on RTP. On the other hand,extraneous factors are difficult to classify and have anunknown impact on the RTP decision.

Discussion

The purpose of this article was to outline and dis-cuss the variables that are relevant to the RTP decisionfollowing sports-related MTBI and to identify a rolefor neuropsychological test data in that decisionprocess. A number of variables have been identified inthe context of several factors that are believed to be im-portant considerations in the RTP process. Each con-cussion is different, and each player or situation is dif-ferent. We have attempted to provide a model thatdepicts a dynamic interplay among variables. Differentsets of variables come into play for each concussionand each concussion may create a unique set of inter-actions. We have not created a prescriptive model thatattempts to classify each variable involved in the deci-sion making process. Our goal was to create an empir-ically testable model that can serve as a heuristic topersonnel involved in the RTP decision.

In developing this model, we are cognizant that somemay argue that the only variables that should be of im-portance in RTP are data that are directly related to med-ical or neuropsychological functioning. In other words,team factors, family factors, and player issues have no

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place in the RTP decision. Although this position maybe considered by some to be an ideal, we believe that itdoes not reflect the struggle that is faced by physiciansand other sports medicine personnel in arriving at a RTPdecision. As noted at the outset, the RTP decision in-volves a complex risk-benefit analysis that comprises adynamic interplay between many variables.

Neuropsychologists must be aware of the context ofthe RTP decision and the variables that come into playfor each decision if they are to adequately serve asconsultants to the team physician. Neuropsychologistshave powerful clinical and research tools and an exten-sive knowledge base that can inform the RTP decision.Most physicians welcome and actively seek out suchconsultation. However, it is imperative that we keep inmind that neuropsychological factors are only one partof a complex model.

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RETURN TO PLAY

MEDICAL FACTORS

Symptoms (Observed & Reported)Radiologic findingsPhysical findings

CONCUSSION FACTORS

Severity of injury (PTA, RTP, LOC)Time from concussionHistory of concussions (number,spacing, severity)

PLAYER FACTORS

Career aspirationsPersonalityStyle of playPhysical symptomsFamily issuesFeelings re: return to play

TEAM FACTORS

Level of play (Elite v. recreational)Position of player on teamImportance of gameOpposing team characteristicsSport specific risk for concussion

EXTRANEOUS FACTORS

Field conditions/ typePlaying surface

Neuropsychological Data

Figure 1. A dynamic model for return to play.

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Original submission May 1, 2002Accepted August 9, 2002

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