Journal of Pediatric Surgery 49 (2014) 341344

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

A community return-to-play mTBI clinic: Results of a pilot program and survey of

high school athletes
Eileen Kelleher , Elizabeth Taylor-Linzey, Lisa Ferrigno, Julia Bryson, Stephen Kaminski
Santa Barbara Cottage Hospital, Rehabilitation and Pediatric Trauma Services, Santa Barbara, CA, USA

a r t i c l e

i n f o

Article history:
Received 16 October 2013
Accepted 16 October 2013
Key words:
Mild traumatic brain injury
mTBI
Concussion
Return to play
RTP
Underreported concussion
Underreported mTBI
mTBI legislation
mTBI clinic
Pediatric
Adolescent
Athlete
High school

a b s t r a c t
Background: High school athletes who sustain a mild traumatic brain injury (mTBI) or concussion are required
to be removed from play until clearance by a provider. A regional pediatric trauma center offered an mTBI
clinic to evaluate students for return to play (RTP).
Methods: An mTBI clinic was developed in collaboration with a high school district containing three schools.
This program evaluated students suffering from sports-related head trauma, specically football injuries.
Community mTBI education was performed, a standardized RTP algorithm was developed, and a postseason
survey was administered to football players.
Results: Twenty-eight students playing football were seen by the mTBI clinic. The average time until RTP for
clinic patients was 16.9 days. Four hundred ve players were surveyed. Of players responding to the survey,
40 (15%) reported sustaining an mTBI during the football season. Of those sustaining an mTBI, 9 (22.5%) did
not report their symptoms.
Conclusion: Although the mTBI rate is similar to reported rates, the unreported mTBI episodes were lower
(22.5%) than previously published self-reported mTBI rates. The RTP algorithm was successful in returning
athletes in 16.9 days. The algorithm and data can be utilized by other organizations in establishment of an
mTBI clinic and RTP program.

Mild traumatic brain injury (mTBI) or concussion, while lacking

a clear denition, carries uncertain management guidelines
despite mandated directives for athletes injured while participating
in high schools sports. At a regional pediatric trauma center, in
conjunction with three local area high schools, we asked if an mTBI
clinic, run by the trauma center, could evaluate and manage
adolescent athletes suffering from concussive events with a standardized return-to-play algorithm.
mTBI is dened as a complex pathophysiological process affecting
the brain, which is caused by a direct or indirect blow to the head [1].
It has also been dened as force transmitted to the head resulting in
an alteration of consciousness. The precipitating event may not
include complete loss of consciousness [2]. This application of force
causes neurochemical, metabolic and physiologic changes within the
brain and throughout the nervous system [2,3]. The period for
recovery from these changes can vary depending on age, history of
previous mTBIs, preexisting conditions and gender [35].

Corresponding author at: Santa Barbara Cottage Hospital, 400 Pueblo W. Pueblo St,
Santa Barbara, CA 93102, USA. Tel.: +1 805 259 5646.
E-mail address: ekelleher@sbch.org (E. Kelleher).
0022-3468/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.10.016

2014 Elsevier Inc. All rights reserved.

The Center for Disease Control (CDC) estimates that sports-related

mTBIs occur at a rate of 1.6 to 3.8 million annually [6]. While
substantial barriers of estimating the incidence of mTBI in adolescent
youth exist, activities where impact to the head occurs put
participants at risk. Powel and Barber-Foss [7] found that mTBIs
were responsible for 5.5% of high school sports injuries, with 63.4% of
these mTBIs occurring in football. Current guidelines from the
American Academy of Neurology (AAN) [8] and American Academy
of Pediatrics (AAP) [9] recommend no return to play on day of injury
or while symptomatic, but specic duration of rest (cognitive or
physical) is not established.
1. Methods
1.1. Program initiation
The Santa Barbara Cottage Hospital (SBCH) pediatric trauma
service and ofcials of a local school district containing three high
schools agreed to pilot a program to provide concussion evaluation to
assist students in return to play (RTP). Of 7500 students, it is
estimated that 1500 students participate in school-sponsored athletics. A subset of 405 high school students playing football became the
focus of the program. The purposes were to evaluate students after a
suspected mTBI and to provide education and guidance on RTP.

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E. Kelleher et al. / Journal of Pediatric Surgery 49 (2014) 341344

Awareness of this clinic was provided by a series of public interest

events that were held in the local community focusing on mTBI in high
school athletes. This occurred just prior to the start of preseason
training for the fall 2012 high school football season. The rst event was
directed to health care providers which included physicians, nurses and
rst responders. The second event was directed to schools and
attended by coaches, athletic trainers, school administrators, student
athletes and their parents. Students playing football at the three high
schools were strongly encouraged to attend by coaching staff at all
three schools, but attendance was not mandatory. The third event was
provided for the community at large. All events featured medical
experts and recognizable spokespersons in the area of concussion.
The clinic became operational to coincide with the rst day of local
high school football practice in August of 2012. The clinic was
conducted through SBCH and was staffed by pediatric trauma service
nurse practitioners. Student athletes sustaining an mTBI were
removed from play after injury by athletic trainers and coaches in
accordance with California law. There was no required symptom
pattern for removal. Removal was performed at the discretion of
trainers and coaches. After removal athletic trainers provided athletes
the option to receive RTP clearance through a health care provider of
their choice or the trauma clinic mTBI program.
1.2. Evaluation algorithm
In collaboration with Pediatric Neurology and Physical Medicine
and Rehabilitation (PMR) departments, the pediatric trauma service

developed an algorithm for treatment and RTP for use in a new mTBI
clinic. Two assessment tools were utilized in the program. ImPACT is
a computerized neurocognitive evaluation that is administered prior
to exposure to at-risk sports. It may also be utilized in evaluation after
concussion and prior to RTP by comparing to preinjury results. All
students playing football underwent ImPACT testing. The Acute
Concussion Evaluation (ACE) [10] is endorsed by the CDC. It provides
information about initial injury and symptoms, persisting symptoms,
concussion history and other risk factors for longer recovery periods.
Additionally, it incorporates management guidelines by provision of
red ags necessitating clinician reassessment and the effects of
exertion as at rest symptoms resolve. The school version also contains
a graded return-to-play explanation and recommendations for
student reintegration into school.
Atthetimeofinjury,athletictrainerscompletedtheAcuteConcussion
Evaluation(ACE)formwiththedetailsoftheinjury.Thisformwasgivento
theparentsofstudentathletes.ParentschoosingtousethemTBIclinicfor
RTP clearance for their child were then scheduled for the next available
appointment. Those appointments included mTBI symptom screening
andaneurologicalexam,andifIMPACTscoreswereavailable,theywere
reviewed. Athletes were evaluated according to the RTP algorithm
(Fig. 1). This was developed based on assessment tools, the neurologic
examoftheathleteandthe1997AANguidelines[11].Thenumberofprior
concussions, grade of concussion, and duration and type of symptoms
were incorporated into an individualized RTP plan.
For athletes who were asymptomatic at their clinic visit, the
completed ACE form for return to school was reviewed with students

Fig. 1. Pediatric RTP.

E. Kelleher et al. / Journal of Pediatric Surgery 49 (2014) 341344

and their parents. This outlined that they could return to school when
symptom-free and after an additional RTP algorithm specied rest
period as well as additional recommendations for school reintegration. Athletes and their parents were educated on brain rest and the
risk of reinjury including second impact syndrome. Athletes and
parents were also educated on a graded return to homework and
school. For symptomatic athletes rescreening occurred after the RTP
algorithm specied interval and, if appropriate, athletes were cleared
for graded return to play at that time. If symptoms persisted beyond
2-week referral to a specialist (i.e., cognitive therapy, neurocognitive
testing, and neurology) was performed. Data collected included
information based on ACE evaluation, including initial and ongoing
symptoms. Data were de-identied and collection was approved by
the institutional review board of SBCH.
1.3. Postseason survey
A post-football season survey was provided to all football
participants in the pilot program high schools. The time period
evaluated in the survey was the football season, from the preseason in
August 2012 through the end of the season in November 2012. The
survey provided a basic denition of an mTBI and asked seven
questions related to mTBIs, including 1) whether the athlete sustained
an mTBI this season and/or in past seasons, and 2) if sustained during
this season if and to whom he reported the mTBI, and 3) the licensed
provider who performed the RTP clearance. Surveys were administered by the athletic trainers at the end of the last football game and
returned to trauma services. No personal identifying information was
required on the survey and data collection was approved by the
institutional review board of SBCH.
2. Results
2.1. Clinic demographics
Twenty-eight male football players were evaluated in the clinic.
The average age of students evaluated in the clinic was 15.3 years
[1318]. The most commonly reported symptom by patients seen for
RTP was headache (90%) (Fig. 2). Most students seen in the clinic had
at least one prior concussion (17/28; Fig. 3). The mean amount of time
until RTP was 16.9 days (range = 539).
2.2. Postseason survey
A postseason survey was distributed to the 405 high school
students playing football eligible for the program. There were 266
respondents and the average age was 15.5 years. Of those responding,
40 (15% of survey responders) had reported having had symptoms
consistent with an mTBI during the football season. Of those
sustaining mTBI based on these symptoms and responding to the
survey, 9 (22.5%) did not report their symptoms to anyone, 18 (45%)

Number of Patients

30

343

Fig. 3. Number of prior concussions sustained by RTP clinic patients.

were cleared in our RTP clinic, 4 (10%) were cleared by a neurologist, 3

(7.5%) were cleared by a pediatrician, 3 (7.5%) were cleared by the
athletic trainer, 1 (2.5%) was cleared by the coach, 1 (2.5%) was not
cleared to RTP and 1 (2.5%) was cleared by an uncategorized provider
listed as an other category on the survey (Fig. 4).
3. Discussion
Current guidelines from American Academy of Neurology (AAN)
[8] and American Academy of Pediatrics (AAP) [9] recommend no
return to play on the day of injury or while symptomatic, but specic
duration of rest (cognitive or physical) is not established. At the time
of institution of our program, the most recent recommendations with
any specics were from the 1997 AAN [11] utilizing the Colorado
Medical Society Guidelines [12]. An mTBI clinic, run under the aegis of
a pediatric trauma center, can evaluate and manage adolescent
athletes suffering from concussive events with a standardized returnto-play algorithm.
The clinic was used for RTP by approximately half of the students
suffering from concussions during the football season. Although some
were seen by other appropriately trained physicians, 10% of students
were cleared by coaches or trainers. Currently, there is no set training
path specically for the assessment of neurologic injury in athletes
nor are there accepted guidelines for the specic RTP management
pathway. Lacking these it is unclear whether unlicensed providers are
appropriate to clear students for RTP after mTBI or are exposed to
liability in doing so [13,14]. We feel that a pediatric trauma center
mTBI clinic and a standardized management RTP algorithm for the
treatment of students suffering from sports-related head trauma can
meet this need until a time when accepted management guidelines
and what constitutes appropriate training are more clearly dened.
This eliminates any potential conict of interest by trainers and
coaches in the management of these injuries.
Substantial barriers to the accuracy of estimating the incidence of
concussion in adolescent youth exist. Many athletes fail to report
concussions because they do not nd them to be serious (60%94%),
feel like concussions are part of game (55%89%), don't want to leave

Headache

25
20

Difficulty
Concentrating
Dizziness

15

Mentally Foggy

10

Noise Sensitivity

Light Sensitivity
Fatigue

Most Common Symptoms

Fig. 2. Most common symptoms at RTP clinic.

Fig. 4. Clearance for RTP.

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E. Kelleher et al. / Journal of Pediatric Surgery 49 (2014) 341344

the game (41%67%), don't know they had a concussion (36%67%),

and don't want to let their teammates down (up to 32%39%) [15,16].
The combination of these factors has resulted in a signicant and
alarming rate of underreporting. It has been reported that up to 53%
80% of athletes may not report their concussion [1517].
Although small in sample size, our underreported rate for potential
mTBI, at 22.5%, is lower than previous reports. This may result from
increased concussion coverage in the scientic, medical, and popular
media, increased knowledge and awareness of concussion symptoms
among athletes and athletic trainers, and possible increased awareness of the consequences associated with concussions [18,19]. This
suggests that a community education and awareness program
initiated by a regional pediatric trauma center, integrated with the
provision of care in an mTBI clinic can both result in a greater
recognition of injuries and reduce the problem of underreporting.
These observational data offer a proof-of-concept report supporting the implementation and impact of a regional pediatric
trauma center mTBI clinic on the management of concussion within
a pilot program.
The algorithm used in this pilot program was based on grade,
history of concussion, symptoms and physical exam. The algorithm
recommends a specic asymptomatic period prior to being cleared for
a graded RTP as suggested by the 1997 AAN guidelines [11]. It is
unclear if this additional rest period is warranted, especially given the
recommendation of a graded RTP before full contact. Current
guidelines do not utilize grade of concussion in RTP clearance and it
is uncertain if this element is important in an algorithm. A randomized
multicenter trial with varying algorithms should be investigated to
determine an appropriate and safe algorithm that could be consistently utilized by providers in an effort to further streamline RTP and
decrease health care costs.
4. Conclusion
A regional pediatric trauma center in conjunction with three
local high schools, was successful in developing a pilot mTBI clinic, to
evaluate and manage adolescent athletes suffering from concussive
events with a standardized return-to-play algorithm. The unreported
mTBI episodes were lower (22.5%) than previously published selfreported mTBI rates suggesting a potential impact of the educational

process involved. The RTP algorithm used was successful in returning

athletes in 16.9 days. This algorithm and data regarding an RTP clinic
can be utilized by other organizations in the establishment of their
own RTP program and justify expanded implementation.
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