by Eugene Bailey MD
In October 2016, the 5th international conference on concussion in sport was held. Previous conferences were held in 2001, 2004, 2008 and 2012. A panel of experts gathered to review approximately 60,000 articles on the subject for the Berlin meetings. As a result of the meetings, a consensus statement was published1 and serves as a summary of the expert’s findings.
To provide a logical flow, the Concussion in Sport Group (CISG) detailed what they refer to as the 11 “R’s” of concussion management. The sections are; Recognize; Remove; Reevaluate; Rest; Rehabilitation; Refer; Recovery; Return to Sport; Reconsider; Residual effects and sequelae; Risk Reduction.
The goal of the CISG consensus statement as recently published was to build on the principles outlined in the previous statements 234 and to develop further conceptual understanding of sports-related concussion (SRC) using an expert consensus-based approach. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgment.
Although the CISG has provided a consistent definition of Sport Related Concussion (SRC) since 2000, the Berlin expert panel modified the previous CISG definition as follows:
5Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:
►► SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
►► SRC typically results in the rapid onset of short-lived Impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
►► SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
►► SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases, symptoms may be prolonged.
The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other comorbidities (e.g., psychological factors or coexisting medical conditions).
For this article, we will focus on the expert panel’s analysis and recommendations as it relates to Sideline Concussion Management. A quick assessment and analysis of the possible symptoms of SRC are extremely important in protecting the safety of that athlete from sustaining additional and possibly more damaging injuries.
Therefore, it’s important to understand what the panel agrees are the signs to look for when doing an assessment of an athlete on the sideline. Here is what they said as it relates to sideline concussion evaluations.
6Recognizing and evaluating SRC in the adult athlete on the field is a challenging responsibility for the health care provider. Performing this task often involves a rapid assessment in the midst of competition with a time constraint and the athlete eager to play. A standardized objective assessment of injury that excludes more serious injury is critical in determining disposition decisions for the athlete. The sideline evaluation is based on recognition of injury, assessment of symptoms, cognitive and cranial nerve function, and balance. Serial assessments are often necessary.
The suspected diagnosis of SRC can include one or more of the following clinical domains:
a. Symptoms: somatic (e.g., headache), cognitive (e.g., feeling like in a fog) and emotional symptoms (e.g., liability)
b. Physical signs (e.g., loss of consciousness, amnesia, neurological deficit)
c. Balance impairment (e.g., gait unsteadiness)
d. Behavioral changes (e.g., irritability)
e. Cognitive impairment (e.g., slowed reaction times)
f. Sleep/wake disturbance (e.g., somnolence, drowsiness)
When a player shows any symptoms or signs of an SRC:
a. The player should be evaluated by a physician or other licensed healthcare provider on site using standard emergency management principles, and particular attention should be given to excluding a cervical spine injury.
b. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no health care provider is available, the player should be safely removed from practice or play, and urgent referral to a physician arranged.
c. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT5 or other sideline assessment tools.
d. The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury.
e. A player with diagnosed SRC should not be allowed to return to play on the day of injury.
When a concussion is suspected, the athlete should be removed from the sporting environment, and a multimodal assessment should be conducted in a standardized fashion (e.g., the SCAT5).
Sporting bodies should allow adequate time to conduct this evaluation. For example, completing the SCAT alone typically takes 10 min. Adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. In some sports, this may require rule changes to allow an appropriate off-field medical assessment to occur without
affecting the flow of the game or unduly penalizing the injured player’s team. The final determination regarding SRC diagnosis and fitness to play is a medical decision based on clinical judgment.
As it relates to sideline evaluation of a possible SRC, these are comments pulled from the Berlin Consensus document.
7 It is important to note that SRC is an evolving injury in the acute phase, with rapidly changing clinical signs and symptoms, which may reflect the underlying physiological injury in the brain. SRC is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. The majority of SRCs occur without loss of consciousness or frank neurological signs.
At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of SRC in the sporting environment. Because of this evolving process, it is not possible to rule out SRC when an injury event occurs associated with a transient neurological symptom. In all suspected cases of concussion, the individual should be removed from the playing field and assessed by a physician or licensed healthcare provider.
A key concept in sideline assessment is the rapid screening for a suspected SRC, rather than the definitive diagnosis of head injury. Players manifesting clear on-field signs of SRC (e.g., loss of consciousness, tonic posturing, balance disturbance) should immediately be removed from sporting participation. Players with a suspected SRC following a significant head impact or with symptoms can proceed to sideline screening using appropriate assessment tools … then proceed to a more thorough diagnostic evaluation.
The recognition of suspected SRC is best approached using multidimensional testing guided by expert consensus.
Recently, the Canadian Concussion Collaborative published what they viewed as the top 5 key messages from the 5th International Consensus Statement on Concussion in Sport. Although 4 of their five key messages were not related to sideline concussion management, one of their key messages was.
8 The use of baseline testing is not necessary:
The Sport Concussion Assessment Tool 5 (SCAT5) is considered useful to help healthcare professionals assess for the possible presence of a concussion immediately after an injury, but should not be used as a stand-alone method to diagnose a concussion. The utility of the SCAT5 as a screening tool appears to decrease significantly 3–5 days after injury. SCAT5 baseline testing is not necessary for interpreting post-injury scores.
In addition, based on current evidence, the widespread routine use of baseline computerized neuropsychological testing is not recommended in children and adolescents. When these tests are used in the post-injury setting, they should optimally be performed and interpreted by an accredited neuropsychologist.
One of the takeaways from the Berlin conference was the continued focus on attempting to have clear and practical guidelines to determine recovery and safe return to play for athletes with an SRC. The consensus document reflects the current state of knowledge and understands that it will need to be modified according to the development of new knowledge. And the authors of the consensus document acknowledge that the science of concussion is incomplete and therefore management and return-to-play decisions lie largely in the realm of clinical judgment on an individualized basis.
But it appears more and more clear that a rapid sideline assessment is critical to exclude a more serious injury and vital in determining the next steps for the athlete based on those symptoms. Also, removing them from play until they are seen and cleared by a healthcare professional is critical.
One of the standout features of the Berlin CISG meeting was the engagement by experts from the TBI, dementia, imaging and biomarker world in the process and as coauthors of the
systematic reviews, which are published in issue 10 of the British Journal of Sports Medicine
(Volume 51, 2017). The consensus document is first and foremost intended to inform clinical practice with the understanding, however, that there is still much more to be learned as it relates to SRC.
1 Downloaded from http://bjsm.bmj.com/ on July 14, 2017
2 Aubry M, Cantu R, Dvořák J, et al; Concussion in Sport (CIS) Group. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clin J Sport Med 2002;12:6–11.
3 McCrory P Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd international conference on concussion in sport, Prague 2004. Br J Sports Med 2005;39:i78–i86.
4 McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport – the third international conference on concussion in sport held in Zurich, November 2008. Phys Sportsmed 2009;37:141–59.
5 Downloaded from http://bjsm.bmj.com/ on July 14, 2017
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8 Canadian Concussion Collaborative – June 2017