by Dr. Eugene Bailey MD
Clinical Question: What are the best-practice guidelines for physicians, athletic trainers and other health care professionals for the management of sport-related concussion
Bottom Line: The best management of concussion involves the entire sports team. A detailed written plan should be developed (likely by the AT) and presented to administrators and coaches. The plan should include a baseline evaluation of athletes, including neurologic history with symptoms and physical examination and objective measure of neurocognitive performance and motor control. When the rapid assessment of concussion is necessary (eg, during competition), a brief concussion-evaluation tool should be used in conjunction with a motor-control evaluation and symptom assessment to support the physical and neurologic evaluation. Once a concussion is diagnosed, the athlete should be immediately removed from further participation, undergo follow up testing using the same protocol as used for baseline assessment and then include a return to play protocol to return to physical activity once cleared by a physician or designate. Lastly, if the concussion is complicated especially patients who are young, who have had multiple concussions or who have premorbid factors may require additional attention. Documentation of the concussion-management plan should be complete and available in case of long-term consequences.
Reference: Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Palm M, Valovich McLeod TC. National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. Journal of Athletic Training 2014; 49(2):245-265.
Study Design: Expert Review using SORT (Strength of Recommendation Taxonomy)
Setting: Sports-related concussion
Education and Prevention
ATs should educate others using appropriate terminology of concussion avoiding colloquial terms like “bell ringer” or “ding”(B). They should educate administrators to ensure that coaches and parents are educated on concussion recognition, assessment and management and appropriate return to play for concussed athletes (B). The AT should also document all aspects of the concussion especially any modifying factors that may impact that they may have on recovery (C).
Evaluation and RTP
Athletes at high risk of concussion (those in contact and collision sports) should undergo baseline examinations before competitive season begins (B). A new baseline should be completed annually on adolescent athletes, those with recent concussion and, when feasible, all athletes (B). The baseline examination should include history (including any symptoms), physical and neurologic examinations, measures of motor control and neurocognitive function (B). The baseline and postinjury examinations should occur in similar environments and baselines should be reviewed for suboptimal performance (C). Any athlete suspected of concussion should be immediately removed from competition and evaluated by a physician or designate (eg. AT) (C). When the rapid assessment of concussion is necessary, a brief concussion-evaluation tool should be used in conjunction with a motor-control evaluation and symptom assessment to support the physical and neurologic evaluation (B). Once a concussion is made, a daily monitoring of the athlete should be done during recovery (C). During the acute postconcussion period, motor-control and neurocognitive testing does not need to be done daily but can wait until athlete is asymptomatic (C). The concussed athlete should not be returned to competition the same day of the injury (C). No concussed athlete should return to play without being evaluated and cleared by a physician or designate (eg, AT) specifically trained and experienced in concussion evaluation and management (C). Young athletes with past medical history that includes multiple concussions, developmental disorder (eg, ADHD), or psychiatric disorder (eg, anxiety or depression) may benefit form referral to a neuropsychologist to administer other testing to determine readiness to return to scholastic and athletic activities (C). A physical-exertion progression should begin only after the concussed athlete demonstrates a normal clinical examination, the resolution of concussion–related symptoms and return to preinjury scores on tests of motor control and neurocognitive function (C). Concussed athletes who do not show typical progression to normal functioning after an injury may benefit from other treatments and therapies (C). Concussion grading scores should not be used to manage patients, rather each athlete should be evaluated on an individual basis (B).
While the use of certified helmets should be enforced by the AT, coaches, parents and athletes must be educated that these are to reduce catastrophic injury (skull fracture or lacerations) but they have not been proven to reduce concussions (B). Helmet use in high-velocity sports (eg, alpine sports, cycling) has been shown to protect against traumatic and facial injury (A). Evidence for use of mouthguards to prevent concussion is lacking but evidence exists that it reduces dental injuries (B). The use of headgear in soccer is neither encouraged or discouraged based on limited data on concussion (C).
Recovery from concussion in children and adolescents may take longer than in adults and may require more prolonged RTP program (B). Age-appropriate concussion tools should be used in younger population (C). Assessment of postconcussion symptoms should employ age-validated symptom scales and include input from parent, teacher or responsible adult (B). Pediatric athletes may require more frequent updates to baseline assessments (B). Athletic trainers should work with school administrators and teachers to include appropriate academic accommodations during concussion recovery (C).
The AT and physician should agree on an appropriate standard concussion home-instruction form. Both oral and written instructions should be given to the athlete and to a responsible adult (C). After concussion, the athlete should avoid all medications except Tylenol unless reviewed by a physician. (C). The concussed athlete should be advised to avoid alcohol, illicit drugs or other substances that may interfere with cognitive function and neurologic recovery (C). After the initial monitoring period, rest is recommended (C). During the acute phase of injury, the athlete should be counseled to avoid mental and physical exertion that makes symptoms worse (C). Concussed athletes should be excused from any activity requiring physical exertion (eg, physical education, etc) (C). School administrators, counselors and teachers should make academic accommodation during the recovery period (C). A concussed athlete should eat a nutritious diet and drink a lot of fluids during recovery (C).
For an athlete with a history of concussions, the AT should adopt a more conservative RTP protocol (B). Referral to a physician or designate with concussion training and experience should be considered for an athlete with multiple concussions, sustaining a concussion with lessening forces, demonstrating increasing symptoms with each injury, or demonstrating changes from baseline brain function (C). The AT should recognize the potential for second-impact syndrome who sustain a second concussion before the resolution of the first injury (C). The AT should be aware of the potential for long-term consequences of multiple subconcussive and concussive impacts (C).