Return to play following a sports concussion: The “added value” of post-exertion assessment

Abstract

Decision of return to play (RTP) after a concussion is critical given the potential consequences of premature RTP. Athletes should not be cleared for full contact activity until they demonstrate normal cognitive functioning on both rest and post-exertion assessments. Accordingly, this study aimed to examine post-exertion cognitive performance in asymptomatic collegiate athletes who were cleared to return-to-play. Twenty-two recently concussed athletes who completed step 4 of Zurich's RTP protocol and 39 teammate controls participated in the study. They completed a Switch task before and after an acute bout of moderate cardiovascular exercise (80%–85% maximal predicted maximal heart rate for 20-minute) on an ergocycle. Based on their performance on both conditions (Rest, Post-exertion), concussed athletes were categorized into the Pass or Fail group. Specifically, they were placed in the Fail group if their performance was 2 SD lower than the control group's average score. A χ2 test was used to test for equality of proportions between conditions. Although, the proportion of athletes categorized in the Fail group was higher in post-exercise (31.82%) relative to rest (22.73%), it did not reach statistical significance (χ2 = 0.20, p = 0.66). Irrespective of condition, 45% of concussed athletes were categorized in the Fail group. Of these, 10% failed on both conditions, 13% failed on rest only, and 22% failed on post-exercise. The current study suggests that 1 out of 2 athletes who successfully completed the RTP protocol exhibited diminished cognitive functions compared to controls. The use of a sensitive cognitive test, combined with physical exertion, can prevent premature RTP in identifying athletes would have otherwise received medical clearance.