Concussion Recognition and Management: Where Are We Now?

Concussions are such a prevalent sport safety topic in the news that I must admit I have days where I don't want to read another article or news story on the topic.  I'm just hoping the day you decide to click on this blog entry you're in the mood to read one more commentary on the topic.  While concussions are not the only injury that can potentially be suffered by our child-athletes, it's the one that has the most legs in the media these days.  This means there is lots of information to sift through when educating yourself. 

I was recently teaching concussion evaluation to a group of students and was looking through the current position statements to see what I wanted to convey to them.  I realized that I had a longer view on the topic given my years in the profession of athletic training and I wondered how I could demonstrate how far we've come in the recognition and management of these injuries despite continued challenges.  The result was an assignment that asked students to compare four different concussion statements by various organizations.  The four statements were:

• National Athletic Trainers' Position Statement:  Management of Sports Related Concussion (2004)
• Consensus Statement on Concussion in Sport (Zurich, 2012)
• American Medical Society for Sports Medicine Position Statement:  Concussion in Sport (2013)
• American Academy of Neurology:  Position Statement:  Sports Concussions (2013)

If completed as directed the assignment would be a table that allowed comparison between statements on a variety of topics ranging from concussion definition, evaluation guidelines, assessment tools discussed, management recommendations, and recommendations specific to youth and adolescent athletes among others.  After completing my answer key for the assignment I began to notice how much we've pushed ahead in just the last 10 years.

Using the NATA (2004) position statement as a starting point and a basis for comparison when reviewing the more recent statements the evidence of changes in practice becomes easier to see.  Many of the things on this list are now more standardized or the supported standard of practice as compared to the guidelines presented in 2004.  Here are some of the highlights I noticed:

• The definition of concussion has been expanded to include descriptions of various injury mechanisms and the pathophysiological response of the brain
• Treating concussions has become an ever expanding team effort
• Grading scales are no longer used to classify concussions in the acute stage
• Same day return to play is not recommended, especially with adolescents and youth
• Various concussion assessments are consistently recommended as a key component of every sideline evaluation and follow up as appropriate, assessments have been clarified and developed to focus on those areas research shows are most impacted by concussion injuries
• Neuropsychological testing continues to be one tool used in the assessment of concussions; but broad stroke baseline testing is not always recommended; it's effectiveness may be better served when using it with specific groups of athletes/patients
• Legislation has been passed in all 50 states that requires concussion education and evaluation guidelines 
• Clear graded return to play protocols are the standard as part of an athlete's return to sports
• Following a concussion athletes must be cleared by a trained medical professional (physician) before returning to play
• Cognitive rest and gradual return to academics has become just as important as physical rest and gradual return to play (although clear guidelines for academic return have yet to be developed, basic recommendations have been provided by the American Academy of Pediatrics)
• We have confirmed via research that teens typically take longer to recover from concussions and it a symptom free return to sport is critical in preventing the possibility of second impact syndrome
• Prevention has focused on education efforts along with legislating key safety steps; despite continued advancement in protective equipment effective prevention starts with limiting the number of head contacts through practice guidelines, game rules and proper techniques

Sometimes it can be hard to sift through all the information out there. but as you see here if we can organize it in a way that allows for easy comparison we can learn a lot about the standard of care and the progress we've made.

Heather L. Clemons, MS, MBA, ATC