Am Fam Physician. 2007 Jun 15;75(12):1770-1773.
to the editor: I appreciate Dr. Whiteside's article on the management of head and neck injuries by sideline physicians that appeared in the October 15, 2006, issue of American Family Physician.1 However, the information on the management of concussion provided in Tables 3 and 4 is about six years out of date. The American Academy of Neurology's grading system2 is no longer recommended for assessment of the severity of a concussion. The leading experts in sports concussion met in Vienna in 2001 and created the Vienna guidelines.3 These guidelines recommend abandoning the American Academy of Neurology's grading system because it does not give a complete picture of the pathophysiology involved. Instead, the authors of these guidelines opted for “Simple” versus “Complex” criteria based on sideline assessment as well as a repeat assessment performed seven to 10 days after the concussion occurred.3 The Vienna guidelines3 advocate that sideline physicians use the Sports Concussion Assessment Tool (SCAT Card), a pocket-sized card that is a quick indicator of impairment on the field and ideally should be given to every athlete as initial screening during the pre-performance examination.4
1. Whiteside JW. Management of head and neck injuries by the sideline physician. Am Fam Physician. 2006;74:1357–62.
2. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee, American Academy of Neurology. Neurology. 1997;48:581–5.
3. Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston KM, Kelly J, et al. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clin J Sport Med. 2002;12:6–11.
4. McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. 2005;39:196–204.
in reply: The management of concussion must be understood in the context of what has been done, what currently is being done, and what might be done based on the evidence. More than 25 guidelines exist for the management of concussion—all of which are based largely or entirely on expert opinion rather than on evidence.
The Vienna guidelines were written by many of the leading authors on sport-related head injury.1 However, I did not reference their work for several reasons. First, the Vienna guidelines emphasize return-to-play decisions rather than on-the-sideline assessment of athletes with concussions. For these decisions, the authors of the Vienna guidelines recommend that all grading scales be abandoned in favor of carefully monitoring the resolution of post-concussive symptoms before a return to play.
With regard to sideline assessment, the authors of the Vienna guidelines endorsed no particular grading system but instead suggested that athletes be queried for symptoms and signs, and they specifically mention the use of Maddock's questions.2 These suggestions are equivalent to those made in my article.3 Second, the American Academy of Neurology grading system and the Cantu guidelines4 are still used by most sideline physicians and athletic trainers. Any physician entering the field of sports medicine should, at the very least, be aware of these guidelines, even though more recent evidence suggests that they should be supplemented by specific testing for neurologic and cognitive deficits.
Finally, the Sports Concussion Assessment Tool (SCAT Card) was published in 2005 after the prague conference, and it is appropriately becoming more commonly used on the side-line.5 The SCAT Card provides the physician with a reminder of concussion symptoms as well as quick assessment tools for the evaluation of cognitive function. The evidence out-lined in my article1 supports the use of this tool as well as other assessment tools, such as the Balance Error Scoring System.6
1. Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston KM, Kelly J, et al. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clin J Sport Med. 2002;12:6–11.
2. Maddocks DL, Dicker GD, Saling MM. The assessment of orientation following concussion in athletes. Clin J Sports Med. 1995;5:32–5.
3. Whiteside JW. Management of head and neck injuries by the sideline physician. Am Fam Physician. 2006;74:1357–62.
4. Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Physician Sportsmed. 1986;14:76–7.
5. McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. 2005;39:196–204.
6. Guskiewicz KM. Postural stability assessment following concussion: one piece of the puzzle. Clin J Sport Med. 2001;11:182–9.
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