Article originally appeared on BOC blog, September 2013. The American Academy of Neurology (AAN) has released it's first update on concussion management in 15 years, basing their findings strictly on data gathered through intensive research, with nary an opinion or bit of anectdotal evidence to be found. With a growing firestorm around the issue of misdiagnosed concussions in professional athletes and an alarming rise in concussions in younger athletes, the study brings to light much needed information about the risks and recommendations for managing concussions. The study has been endorsed by some heavy-hitters in the world of neurology and athletics, including the American Football Coaches Association, the National Academy of Neuropsychology, the National Athletic Trainers Association, the National Football League Players Association, the National High School Coaches Association, and the Neurocritical Care Society. The AAN aims to answer four crucial questions when it comes to dealing with concussions, particularly in athletes. The findings can be boiled down to a few salient points, including the most important one: Suspect a concussion? Get your butt (and head) off the field. Following is a breakdown of the questions the AAN study answered and their best practice recommendations.
1. What factors increase/decrease concussion risk?
Based on the ratio of males to females in contact sports, it's no surprise that males register the highest number of concussions. But that doesn't mean female athletes are less likely to suffer a concussion. In fact, females who participate in soccer or basketball probably face a higher risk of concussion. For male athletes, the higher risk sports are football and rugby, with no data to support the effectiveness of one type of football helmet over another.
2. What diagnostic tools identify those with concussion and those at increased risk for prolonged issues?
The AAN recommends several diagnostic tools for licensed health care professionals (LHCP) to use to assess potential concussions, including the Post-Concussion Symptom Scale, the Balance Error Scoring System, and the Sensory Organization Test. They've even developed a free mobile app for use by coaches, athletes and medical staff lacking in concussion experience: The "Concussion Quick Check" is a quick reference app that helps identify the common signs of a concussion, finds a Neurologist using the users current location or by doing a city/state search, and provides state specific concussion laws. A Neurologist or physician with the proper medical training should always be consulted before an athlete returns to play (RTP). It can literally mean the difference between life and death and should never be left up to the coach, parents or an inexperienced LHCP. One step that can assist in identifying and assessing possible concussions is the presence of a certified athletic trainer. Athletic trainers are equipped with skills that allow them to block out the distractions that exist during games and focus on the athlete. They're also trained to be 100% objective when evaluating athletes, less prone to overlook suspected symptoms in favor of allowing the athlete to return to the field.
3. What clinical factors identify those at increased risk for severe or prolonged post-concussion impairments, recurrent concussions, or chronic neurobehavioral impairment?
The study concluded that there is a high likelihood that a history of concussions can cause longer and more severe symptoms and cognitive deficits and returning to play (and the classroom) too soon after a positive diagnosis can have severe and lasting repercussions, especially within the first 10 days. Currently, as many as 40 percent of high school athletes who suffer concussions return to action too soon, raising the risk for more severe injuries.
4. What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term ramifications?
The AAN study could draw no conclusions regarding the effects of post-concussion activity on the recovery from a sports related concussion or the likelihood of developing chronic complications.
AAN Practice Recommendations
Preparticipation Counseling
School staff, parents and athletes should be educated by a licensed healthcare professional about the risks of concussions. There are more and more resources to be found for educating everyone involved in an athletes life, including "Heads Up: Concussion In Youth Sports" from the CDC, and a "Summary of Evidence-based Guideline for Patients and Their Families" from the AAN.Suspected Concussion
- Sideline staff, including coaches and LHCPs, should make use of the standardized sideline assessment tools and report the results to a clinical LHCP, who will be evaluating the affected athlete, paying particular attention to the results of at risk athletes.
- Team personnel should immediately remove the athlete from play. Not after a few minutes or another run... Immediately. And not let them return to play no matter on how hard they insist they are "just fine".
- Neuroimaging only needs to be used to rule out more serious TBI such as an intracranial hemorrhage.
Management of Diagnosed Concussion
- The athlete should never be allowed to return to play (RTP) until a LHCP judges that the concussion has healed completely. They should also not be allowed to RTP until they are asymptomatic off any medications.
- Due to younger athletes facing higher risks, they need to be managed more conservatively, with careful attention being paid to preteen and younger athletes.
- Clinical LHCP can use additional information, like neurocognitive testing, to more accurately assess the athlete's recovery before allowing RTP.
- There currently isn't enough evidence to suggest that complete rest after a diagnosed concussion is beneficial. Activities that don't aggravate symptoms and don't carry the risk of a repeat concussion may be recommended.
- When they are deemed ready to return to physical and cognitive activity, the AAN recommends a gradual increase to their regular levels with careful monitoring. They also recommend cognitive restructuring. They found that using this intervention for TBI has shown benefits in decreasing the proportion of athletes who develop chronic postconcussion syndrome.
- Retirement from play is a serious judgement that a LHCP hates to make but must take into account, specifically when the athlete has suffered multiple concussions. If, after careful assessment, retirement is the best option, this needs to be communicated to the athlete, helping them to understand the dangerous ramifications should they decide to return to play after being advised not to.