Updated Expert Guidelines on Risks for and Management of Sports Concussion

There is no known treatment that speeds recovery or postconcussion impairment; monitoring to full recovery is critical.

Management of the millions of athletes who experience sports-related concussion annually is controversial. The American Academy of Neurology convened a panel of experts to review relevant literature published since 1955 and update the 1997 clinical practice guideline. The full guideline and supplementary materials are available at http://www.aan.com/go/practice/concussion.
The following highlights of the update are helpful to primary care clinicians who care for athletes with concussion on the field or in the office setting:

• Concussion risk is greater for female athletes than for male athletes participating in the same sport (e.g., soccer and basketball).
• Concussion risk is greater in American football and Australian rugby than in other sports.
• Head protection probably decreases risk, but no specific type of headgear can be recommended.
• Standardized assessment tools (e.g., Post-Concussion Symptom Scale and Standardized Assessment of Concussion) are relatively accurate in identifying concussion and useful for monitoring resolution of symptoms. These tools are not diagnostic and should only be used as an adjunct to traditional clinical evaluation.
• Neuroimaging is not needed unless evidence exists of more severe trauma, clinical deterioration, loss of consciousness, post-traumatic amnesia, or focal neurologic deficits.

The critical objective in caring for concussed athletes is to monitor each athlete to complete resolution of symptoms before allowing them to return to play or practice. High-school age and younger athletes might require more conservative care and longer time to return to play. Prior grading systems have not proven useful; individual monitoring to full recovery off all medication, with graded physical activity to full participation, is the most important clinical objective. There is no known treatment that speeds recovery or prevents long-term impairment. Prior concussion predicts future concussions, and that plus prolonged recovery may predict long-term sequelae.
— Thomas L. Schwenk, MD

The Journal Watch Neurology Perspective

Although huge gaps remain in our understanding of both the short- and long-term sequelae of concussions, a growing body of evidence suggests that even apparently mild traumatic brain injury can cause significant impairments in cognition, mood, and function. This argues for a cautious and conservative approach — such as the one outlined in these guidelines — to sports-related concussions, especially since high-risk sports are mostly played by children and young adults. Given neurologists' experience with other types of brain injury and the management of chronic neurological symptoms, neurologists may be valuable in assisting primary care physicians and other healthcare providers in managing diagnosed concussions, especially in patients with persistent post-concussive symptoms.

— Hooman Kamel, MD
Giza CC et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology 2013 Mar 18 ; [e-pub ahead of print]. (http://dx.doi.org/10.1212/WNL.0b013e31828d57dd)
— Thomas L. Schwenk, MD, and Hooman Kamel, MD
Published in Journal Watch Neurology April 16, 2013