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New Guideline For Managing Concussion

19 Mar 2013

The American Academy of Neurology has released its guideline for evaluating and managing athletes with concussion. The AAN says that over one million sportsmen and sportswomen in the USA experience a concussion annually. This is the first concussion update in 15 years.

According to the AAN (American Academy of Neurology), which published the new guideline in Neurology (March 18th, 2013 issue), Americans now have an objective, evidence-based review of the literature by a committee of experts from various fields.

The Academy added that its guideline has been endorsed by a wide range of sports, medical and patient groups, including: The National Association of Emergency Medical Service Physicians, the Neurocritical Care Society, the American Football Coaches Association, the National Football League Players Association, the Child Neurology Society, the National Academy of Neuropsychology, the National Association of School Psychologists, and the National Athletic Trainers Association.

If you suspect concussion, remove the athlete from play immediately

Co-lead guideline author, Christopher C. Giza, MD, with the David Geffen School of Medicine and Mattel Children’s Hospital at UCLA, explained that it is imperative that any athlete who is suspected of experiencing concussion be removed from play straight away.

Dr. Giza said:

“We’ve 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. There is no set timeline for safe return to play.”

The updated guideline recommends:

  • Immediate action – any athlete with suspected concussion must be taken out of the game immediately
  • See a specialist – that athlete should not be allowed to return until an examination has been carried out by a licensed health care professional trained in concussion
  • A gradual return to play – return to play should be done slowly, and only after acute symptoms have completely disappeared
  • Children and teenagers – athletes up to high school age with a concussion “should be managed more conservatively” regarding when they be allowed to come back to the game. According to available evidence, this age group takes longer to recover than older sports people

The authors of the guideline gathered and examined all available evidence that was published in academic journals up to the end of June 2012.

The author panel included a broad range of expertise, the AAN informed. They spent “thousands of work hours” locating and examining scientific studies. They excluded studies that did not provide compelling evidence to make recommendations, such as expert opinions or anecdotal accounts. Each study was independently analyzed and graded by two or more authors.

The guideline says that:

  • The sports with the greatest risk of concussion are football and rugby, and then hockey and soccer, among males
  • Among females, soccer and basketball have the greatest risk of concussion
  • A sportsman or sportswoman who has already experienced at least one concussion is more likely to be diagnosed with another, compared to athletes with no history of concussion
  • After being diagnosed with concussion, the patient is at greatest risk of being diagnosed with another concussion during the following ten days
  • The authors found no compelling evidence that demonstrated that one type of football helmet is better than another at protecting the athlete against concussion.
  • Doctors who are trained in treating concussion should look for ongoing symptoms, particularly fogginess and headache, a history of concussions, and younger age in the athlete. These factors have been individually associated with longer recovery after a concussion.
  • Athletes with a prior concussion, long exposure to a sport, and those that have the ApoE4 gene have a higher risk of experiencing chronic neurobehavioral impairment.

The AAN emphasized that “Concussion is a clinical diagnosis. Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychological testing (paper-and-pencil and computerized) and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis.”

What are the signs and symptoms of concussion?

  • Headache
  • Sensitivity to light
  • Sensitivity to sound
  • Changes to reaction time
  • Changes in judgment
  • Changes in speech
  • Changes in sleep
  • Loss of consciousness, or a ” blackout” (occurs in less than 10% of concussions)

Jeffrey S. Kutcher, MD, with the University of Michigan Medical School in Ann Arbor and a member of the AAN, said:

“If in doubt, sit it out. 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.”

Should there be absolute rest after a concussion? – the guideline states that there is insufficient compelling evidence to support absolute rest after concussion, but the athlete should be immediately removed from play.

Part of concussion management may include activities known not to worsen symptoms and which are not linked to a risk of repeat concussion.

Sports Concussion Tool Kit – American Academy of Neurology(opens in a new tab)

The AAN has also launched an app called “Concussion Quick Check”(opens in a new tab) which is available for iPad, Android, IOS (Apple) and some other mobile devices. It is aimed at helping coaches, trainers, parents and other athletes rapidly decide whether somebody is experiencing concussion and needs to see a doctor.