What are the criteria to clear a 17-year-old patient from a concussion diagnosis?

Clearing a 17-Year-Old from a Concussion Diagnosis

A 17-year-old athlete can only be cleared from a concussion when they are completely asymptomatic at rest, have successfully completed a graduated return-to-play protocol without symptom recurrence, and have returned to their baseline on all neuropsychological and balance testing. 1, 2

Required Components for Concussion Clearance

1. Complete Resolution of Symptoms

• All concussion symptoms must be fully resolved at rest, including:
  • Headache (most common symptom)
  • Dizziness and balance problems
  • Visual disturbances
  • Cognitive symptoms (difficulty concentrating, mental "fogginess")
  • Emotional symptoms (irritability, anxiety)
  • Sleep disturbances 2

2. Neurological Examination

• Normal neurological examination including:
  • Glasgow Coma Scale score of 15
  • Normal pupillary responses
  • Normal cranial nerve examination
  • Normal balance testing (such as BESS or Romberg test)
  • No evidence of retrograde or anterograde amnesia 1, 2

3. Neurocognitive Testing

• Return to baseline on standardized neurocognitive assessment tools:
  • Computerized tests (ImPACT, ANAM, CogState, or HeadMinder)
  • Sport Concussion Assessment Tool (SCAT-5)
  • Balance Error Scoring System (BESS) 1

4. Successful Completion of Graduated Return-to-Play Protocol

The athlete must complete all stages without symptom recurrence:

1. Stage 1: Light aerobic exercise (walking, swimming, stationary cycling) at <70% maximum heart rate
2. Stage 2: Sport-specific exercise (skating drills in hockey, running drills in soccer)
3. Stage 3: Non-contact training drills (passing drills, progressive resistance training)
4. Stage 4: Full-contact practice (following medical clearance)
5. Stage 5: Return to competition/full activity 1, 2

Each stage typically requires 24 hours, with progression to the next stage only if asymptomatic. If symptoms recur at any stage, the athlete must return to the previous asymptomatic stage after 24 hours of rest 1.

Who Can Clear the Athlete

Clearance must be provided by a physician with experience in concussion management 2. This is particularly important for adolescents, as they:

• May have longer recovery times than adults
• Are more vulnerable to "second impact syndrome"
• May experience more significant cognitive impacts affecting school performance 1, 2

Important Considerations for Adolescents

• Adolescents typically require more time to recover than adults, with high school athletes showing longer recovery times than collegiate athletes 3
• Female adolescents may have longer recovery times than males 3
• Return-to-learn protocols should be completed before full return-to-play 2
• Neuroimaging (CT or MRI) is not routinely recommended for concussion diagnosis or clearance unless there are concerns for more serious injury 1

Common Pitfalls to Avoid

1. Premature clearance: Clearing an athlete based solely on their self-report of being symptom-free without objective testing
2. Overlooking subtle symptoms: Cognitive or emotional symptoms may be less obvious than physical ones
3. Ignoring academic performance: School performance should return to baseline before sports clearance
4. Skipping stages in the return-to-play protocol
5. Failing to document the clearance process and decision-making

Special Considerations

• Athletes with a history of multiple concussions may require more conservative management 3
• Those with pre-existing conditions (migraine, depression, ADHD) may have more complex recovery patterns 3
• If symptoms persist beyond 2-3 weeks, referral to a concussion specialist is recommended 2

Remember that concussion is a functional rather than structural injury, and proper clearance is essential to prevent recurrent concussions, prolonged recovery, and potential long-term consequences 4.