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.
DEFINING CONCUSSION:
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.
4th
INTERNATIONAL CONFERENCE ON CONCUSSION STATEMENT (Zurich):
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.
AMERICAN
ACADEMY OF NEUROLOGY (AAN):
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.
CONCUSSION DIAGNOSIS:
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.
CONCUSSION ASSESSMENT TOOLS:
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).
NEUROPSYCHOLOGICAL TESTING:
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.
CONCUSSION EVALUATION PROCESS:
According
to Zurich when an athlete shows any features of a concussion a player
should:
- Be evaluated onsite by a LHCP,
- If no HLCP available player should be safely removed from play IMMEDIATELY,
- Assessment of concussion should be made once first aid concerns have been addressed (rule out neck injury),
- 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,
- 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.
CONCUSSION MANAGEMENT AND RETURN TO PLAY:
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.
OTHER INFORMATION:
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.
SUMMARY:
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.
ADDITIONAL
RESOURCES:
(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
Submitted by Heather L. Clemons, MS, MBA, ATC
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