Thursday, March 21, 2013

Key Concussion Statements Released

Two prominent organizations have released statements regarding sports-related concussions in the last week or so.  The first statement released was the Consensus Statement on Concussion in Sport:  The 4th International Conference on Concussion in Sport Held in Zurich, November 2012 and the second was the Summary of Evidence-Based Guideline Update:  Evaluation and Management of Concussion in Sport:  Report of the Guideline Development SubCommittee of the American Academy of Neurology.  This week’s blog post will attempt to highlight some of the key points and additional resources associated with these statements. Where possible I will discuss what it may mean for concussion management moving forward.  Since the publication of these documents, a variety of posts and/or stories including opinion and reaction have been published.  It is not the purpose of this blog post to provide my personal opinion on each statement, but to highlight the key information presented in each and allow informed readers to develop their opinions based on their understanding of this available information.

While each statement defines a concussion using different language, the key components are the same.  A concussion is a brain injury as the result of a direct or indirect force to the head resulting in functional changes to the brain.

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.  Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include 1) direct blow to head or face, or indirect blow to the body; 2) results in rapid onset of short-lived impairment neurological function; 3) may result in meuropathological changes, but the acute clinical symptoms reflect a functional disturbance rather than structural injury; ad 4) results in a graded set of clinical symptoms that may or may not involve loss of consciousness.  Resolution of the symptoms typically follows a sequential course, but may be prolonged in some cases.

Concussion is recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousnesss (LOC).

According to the 4th International Conference Consensus Statement a majority (80 – 90%) of concussions resolve in 7 – 10 days, but can be longer in children and adolescents.  Very few concussions present with loss of consciousness.

Diagnosis of concussion should be made by a licensed health care professional (LHCP), [athletic trainers fall into this category] according to both the AAN and Zurich statements.  The Zurich statement provides a much more detailed list of signs and symptoms that can lead to a diagnosis of concussion including: physical and/or emotional symptoms, physical signs, behavioral changes, cognitive impairment, sleep disturbance. 

The Zurich statement recommends the SCAT3 and Child SCAT3 when initially evaluating concussions.  The Sport Concussion Assessment Tool (SCAT) is a combination of injury history, Graded Symptom Checklist (GSC), cognitive function assessment, Standard Assessment of Concussion (SAC), and Balance Error Scoring System (BESS).  The AAN statement does not discuss the SCAT3 specifically, but does address some of the included assessments on an individual basis with moderate to high effectiveness with regards to recognizing concussion. AAN does recommend a combination of assessments work best, but does not recommend a specific combination of assessments.

Both Zurich and AAN reiterate that CTs cannot diagnose a concussion, but may be useful in ruling out more serious traumatic brain injuries (TBI).

Zurich recommends that neuropsychological assessment should not be the sole basis of management decisions, but should be seen as an aid to the clinical decision-making.  Formal NP testing is not required for all athletes, but when used should be utilized by trained neuropsychologists and should be one part of the return to play (RTP) decision-making process for the medical professional caring for the athlete.  Baseline testing was not considered a mandatory aspect of assessment, with insufficient evidence to mandate such testing according to Zurich.  Baseline may be appropriate in individual cases, but not as a standard of practice at this time.  AAN recommends that when NP is used that it be interpreted by a qualified neuropsychologists and should not be used in preadolescents as evidence to support such use is lacking.

According to Zurich when an athlete shows any features of a concussion a player should: 
  1. Be evaluated onsite by a LHCP,
  2. If no HLCP available player should be safely removed from play IMMEDIATELY,
  3. Assessment of concussion should be made once first aid concerns have been addressed (rule out neck injury),
  4. Do not leave the player alone following injury; should be consistently monitored for the first few hours after injury, it is possible that symptoms could worsen during this time,
  5. Should not return to play on the day of injury.

AAN provides a very similar recommendation regarding concussion evaluation.  It provides additional emphasis on not returning athletes to play on the same day they have been suspected (not diagnosed) of having a concussion, particularly for adolescent athletes.  AAN also emphasizes that athletes must ultimately gain medical clearance for a LHCP in order to begin the return to play process.  Many states now also require these steps as part of their concussion management protocols as part of a legal mandate.

Zurich emphasizes BOTH physical and cognitive rest until acute symptoms resolve. This seems particularly important for adolescent athletes and modification of activities such as texting and watching television should be considered as part of the cognitive rest component.

Both Zurich and AAN recommend a graded RTP program prior to full medical clearance and return to sport.  Zurich recommends a minimum of 24 – 48 hours of rest (symptom free) prior to beginning return to play protocol.  Also, child and adolescent athletes should not return to sport until they have returned to schools successfully.  A specific graded RTP protocol is provided in the Zurich statement, but it should be individualized and progressed only when the athlete is symptom free following completion of the current stage.  Children and adolescents recover more slowly and the RTP should take a more conservative approach.

When it comes to other factors likely to affect the likelihood of concussion or prolonged symptoms from a concussion both Zurich and AAN agree that a previous history of concussion makes an athlete more susceptible to future concussions.  The AAN statement goes on to list other factors that may increase risk including being a male in collision sports such as football or rugby.  Some evidence demonstrates that female athletes are at greater risk for concussion in soccer and basketball as compared to their male counterparts.  Body checking in hockey is also likely to increase risk.  Zurich lists several factors as “modifying factors” and conveniently lists them in a table as part of their statement. 

Understanding the role of protective equipment in the prevention of concussions has come into further focus and according to both Zurich and AAN there is currently no evidence that shows mouth guards or helmets prevent the occurrence of concussions.  Mouth guards do prevent dental and orofacial injuries, while helmets can reduce forces placed on the brain, but this does not translate to preventing concussions.

The ability to predict whether an athlete is at increased risk for prolonged or chronic impairment following diagnosis of a concussion is difficult at best.  According to the AAN statement there is some evidence that shows that elevated post concussion symptoms, lower SAC scores, and BESS deficits could be associated with more severe or prolonged postconcussive impairments.

The AAN goes on to recommend that education of school-based professionals (coaches, teachers, administrators, etc.) by LHCP trained in understanding concussion and their prevention is critical.  The LHCP should also be involved in the education of athletes and parents regarding the risks, recognition and management of concussions.

After reviewing both statements it seems there is much that Zurich and AAN can agree on when it comes to diagnosing and managing concussions.  The Zurich statement seems to be focusing on sports-related concussions as a whole and does include some additional information about CTE and other topics not addressed by AAN.  The AAN statement clearly focuses on concussions as it relates to children and adolescent athletes whereas Zurich includes information about this population as part of a greater athlete population.   In the end I think the AAN has it right when it recommends education of school-based professionals who will be dealing with concussed athletes in some way.  I would argue that education is the one biggest tool we have to improve prevention, diagnosis and management of sports-related concussion whether they happen to a child or a professional athlete.

(this includes some fact sheets and the new app)

HERE is Beth at a recent ASA event talking about the AAN Guidelines.

Submitted by Heather L. Clemons, MS, MBA, ATC

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