New Challenges in Assessing and Managing Concussion in Sports
Am Fam Physician. 2007 Oct 1;76(7):948-949.
In a recent AFP article on sideline management of head and neck injuries, Dr. White-side correctly stated that there is no general agreement on clinical markers of concussion severity or on the appropriate management of concussions.1 However, experts have provided physicians with consensus guidelines to try to standardize the approach to sports concussion. These recommendations continue to evolve. Two recent consensus statements have garnered much attention in the sports medicine community because they present significant departures from current concussion management guidelines.2–4 One statement was a report from the First International Conference on Concussion in Sport, held in Vienna, Austria, in 2001,5 and the other was a report from the Second International Conference on Concussion in Sport, held in Prague, Czech Republic, in 2004.6 These conferences were organized by the International Ice Hockey Federation, the Fédération Internationale de Football Association, and the International Olympic Committee. Participants included experts in neurology, neurosurgery, trauma surgery, sports medicine, and sports psychology. The goal of these conferences was to provide recommendations to improve the safety and health of athletes with concussive injuries.
The first change of note was a new definition of concussion, which says that a concussion is “a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.” Although at first glance this definition appears to be vague and nonclinical, the statement authors refine their definition by including specific symptoms, such as loss of consciousness and amnesia. The pathophysiologic definition is broad by design to discourage physicians from relying too heavily on any one symptom or finding when estimating concussion severity, a major theme of both papers.5,6
A significant departure from historical concussion management proposed in these statements is the recommendation to completely abandon previous grading systems. The authors of both reports state that concussion severity can only be determined in retrospect after symptoms have cleared, when the neurologic examination is normal, and when cognitive function returns to baseline.5,6 Based on this premise, physicians should no longer prospectively grade concussions by the presenting signs and symptoms, but instead focus on protecting the athlete from further injury until signs and symptoms have passed. Only then are we able to determine the severity of the injury. The statement authors propose that an athlete should not return to play the same day after any symptom of concussion. Instead, once all signs and symptoms have resolved, the athlete should follow a defined progression of physical activities, and if completed asymptomatically, return to play. This process, as described, would take a minimum of five days. This is a significant change from previous grade 1 concussion management guidelines, which often allow a same-day return to play.
Although the first conference statement offers no classification system for concussion, the second conference statement does, recognizing that there are athletes with persistent concussive symptoms. Sports concussions should now be classified as simple or complex. A simple concussion is an injury that progressively resolves without complication over seven to 10 days. A complex concussion involves an athlete who suffers persistent symptoms (including symptoms induced by exertion), specific sequelae (e.g., concussive convulsions, prolonged [greater than one minute] loss of consciousness), or prolonged cognitive impairment following the injury. This may also include athletes who experience multiple concussions over time or those who have repeated concussions with progressively less impact force. With complex concussions, formal neuro-psychological testing and other studies, presumably computed tomography or magnetic resonance imaging, should be considered. The statement authors also recommended that physicians with specific expertise in the management of concussive injury, such as sports medicine physicians, sports neurologists, or neurosurgeons, should manage these complex injuries.6
Difficulty remains in determining objective data to quantify concussion severity and to guide return-to-play decisions. The authors of the second conference report state that neuropsychological testing is valuable in patients with complex concussion. They also state that cognitive recovery from concussion may precede or follow resolution of other clinical symptoms.6 Because of this variability, assessment of cognitive function should not form the sole basis of return-to-play decisions. It may still be an important aid in the decision; however, the final decision should be based on complete resolution of all concussive signs and symptoms.
Because traditional neuropsychological testing and its computerized analog are expensive and not widely available, the authors of the statement from the second conference devised the Sport Concussion Assessment Tool (SCAT), which is a brief assessment of signs and symptoms of sports concussion. It was developed for physician assessment and patient education and includes evaluation of memory, cognitive assessment, and neurologic screening, as well as educational information for athletes and their families. The SCAT is the result of combining several existing validated tools into a new standardized instrument and, although it has not been formally validated, the authors state that it is supported by scientific literature and has held up well in clinical experience. The SCAT can be found in the original report at http://www.cjsportmed.com/pt/re/cjsm/pdfhandler.00042752-200503000-00003.pdf.6
Some of the changes in sports concussion management recommended by the authors of the two consensus statements are certainly controversial, but are geared toward the best interests and health of the players. I encourage anyone who cares for athletes to refer to the original conference documents for complete details and return-to-play considerations.
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. Report of the Quality Standards Subcommittee. Neurology. 1997;48:581–5.
3. Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Physician Sportsmed. 1986;14:75–83.
4. Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play. J Athl Train. 2001;36:244–8.
5. Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston K, Kelly J, et al., for the Concussion in Sport Group. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med. 2002;36:6–10.
6. McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, et al., for the International Symposium on Concussion in Sport. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. 2005;15:48–55.
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