Any athlete with a possible concussion should be immediately removed from play pending an evaluation by a licensed health care provider trained in assessing concussions and traumatic brain injury, according to a new guideline from the American Academy of Neurology.
The guideline for evaluating and managing athletes with concussion was published online in the journal Neurology on March 18 (doi:10.1212/WNL.0b013e31828d57dd) in conjunction with the annual meeting of the AAN. The guideline replaces the Academy’s 1997 recommendations, which stressed using a grading system to try to predict concussion outcomes.
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The guideline for evaluating and managing athletes with concussion was published online in the journal Neurology on March 18.
The new guideline takes a more individualized and conservative approach, especially for younger athletes. The new approach comes as many states have enacted legislation regulating when young athletes can return to play following a concussion.
"If in doubt, sit it out," Dr. Jeffrey S. Kutcher, coauthor of the guideline and a neurologist at the University of Michigan in Ann Arbor, said in a statement. "Being seen by a trained professional is extremely important after a concussion. If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor. You only get one brain; treat it well."
The new guideline calls for athletes to stay off the field until they are asymptomatic off medication. High school athletes and younger players with a concussion should be managed more conservatively since they take longer to recover than older athletes, according to the AAN.
But there is not enough evidence to support complete rest after a concussion. Activities that do not worsen symptoms and don’t pose a risk of another concussion can be part of the management of the injury, according to the guideline.
"We’re moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return to play be assessed in each athlete individually," Dr. Christopher C. Giza, the co–lead guideline author and a neurologist at Mattel Children’s Hospital at the University of California, Los Angeles, said in a statement. "There is no set timeline for safe return to play."
The AAN expert panel recommends that sideline providers use symptom checklists such as the Standardized Assessment of Concussion to help identify suspected concussion and that the scores be shared with the physicians involved in the athletes’ care off the field. But these checklists should not be the only tool used in making a diagnosis, according to the guidelines. Also, the checklist scores may be more useful if they are compared against preinjury individual scores, especially in younger athletes and those with prior concussions.
CT imaging should not be used to diagnose a suspected sport-related concussion, according to the guideline. But imaging might be used to rule out more serious traumatic brain injuries, such as intracranial hemorrhage in athletes with a suspected concussion who also have a loss of consciousness, posttraumatic amnesia, persistently altered mental status, focal neurologic deficit, evidence of skull fracture, or signs of clinical deterioration.
Athletes are at greater risk of concussion if they have a history of concussion. The first 10 days after a concussion pose the greatest risk for a repeat injury.
The AAN advises physicians to be on the lookout for ongoing symptoms that are linked to a longer recovery, such as continued headache or fogginess. Athletes with a history of concussions and younger players also tend to have a longer recovery.
The guideline also include level C recommendations stating that health care providers "might" develop individualized graded plans for returning to physical and cognitive activity. They might also provide cognitive restructuring counseling in an effort to shorten the duration of symptoms and the likelihood of developing chronic post-concussion syndrome, according to the guideline.
The guideline also included a number of recommendations on areas for future research, including studies of pre–high school age athletes to determine the natural history of concussion and recovery time for this age group, as well as the best assessment tools. The expert panel also called for clinical trials of different postconcussion management strategies and return-to-play protocols.
The guidelines were developed by a multidisciplinary expert committee that included representatives from neurology, athletic training, neuropsychology, epidemiology and biostatistics, neurosurgery, physical medicine and rehabilitation, and sports medicine. Many of the authors reported serving as consultants for professional sports associations, receiving honoraria and funding for travel for lectures on sports concussion, receiving research support from various foundations and organizations, and providing expert testimony in legal cases involving traumatic brain injury or concussion.