New guidance reviews evaluation, treatment for sport-related concussion

HealioJune 24, 2021

The Team Physician Consensus Conference released a new guidance document to help team physicians manage sport-related concussions in athletes of all ages.

“The diagnosis of concussion is challenging because it is a clinical one with symptoms that are nonspecific, but they do have to be tied to a mechanism of injury,” Margot Putukian, MD, FACSM, FAMSSM, member of the executive committee for the Team Physician Consensus Conference, told Healio Orthopedics. “If you do not have a mechanism of injury, it is not a concussion.”

The 22nd paper in a series of annual consensus documents written for the practicing team physician, the guidance document on sport-related concussion was developed through a project-based alliance of the American College of Sports Medicine, the American Academy of Family Physicians, the American Academy of Orthopaedic Surgeons, the American Medical Society for Sports Medicine, the American Orthopaedic Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine.

Pre-season planning, education

Within the guidance, members of the alliance recommend developing or reviewing an emergency action plan and performing a preparticipation assessment in the athletic year prior to any practice or competition, including protocols and policies for recognition and acute management of sport-related concussion. During this period, athletes, coaches, parents, administrators, referees and health care providers should be educated about sport-related concussions in a manner consistent and compliant with state law, governing body and school district requirements, according to the guidance.

“There are a lot of tools that are out there [for education],” Putukian said. “The CDC has a heads-up program that provides education and the Concussion in Sport Group have a concussion recognition tool, which provides signs and symptoms of concussion.”

Sport-related concussions are treatable

When a sport-related concussion is suspected in an athlete, the guidance reports that evaluation may occur on the field of play or sideline, off field and should continue with serial evaluations.

“Everybody wants to make that evaluation right away when the player comes off the field,” Karen M. Sutton, MD, associate professor at Weill Cornell Medicine and attending sports medicine surgeon at Hospital for Special Surgery, told Healio Orthopedics. “But taking the player off the field, giving it some time, letting some plays go on and making the decision a few minutes later is not a bad thing, either. I think people always want to rush to a conclusion and a diagnosis but sometimes it evolves over time.”

Putukian noted team physicians should understand that sport-related concussions are treatable, with a recovery time of within 2 to 4 weeks in most athletes. Symptom-directed management of sport-related concussions includes appropriate rest, aerobic exercise, sleep hygiene, proper nutrition and hydration, while current evidence suggests prolonged, strict rest may impede recovery, according to the guidelines.

“The days of putting somebody in a dark room and not having any kind of stimulus at all are outdated,” Putukian said. “We know that after an initial 24 to 48 hours of relative cognitive and physical rest that exercise is good for the brain. This makes intuitive sense, and also allows individuals to play an active role in their recovery.”

Persistent symptoms after concussion

Team physicians should also be aware that some athletes may experience persistent symptoms after concussion, including fatigue, mood changes and anxiety, headache or migraine, sleep disturbance and oculomotor symptoms. Putukian said athletes with persistent symptoms after concussion should undergo thorough evaluations to identify the cause and then be managed with symptom-targeted treatment.

“It is unclear in terms of why some individuals have persisting symptoms, although it appears that those individuals that have a high symptom burden and severity initially after injury, a well as those with prior history of concussion or pre-existing mood or other disorders appear to be at a greater risk,” Putukian said.

Athletes who either continued to play with a concussion or returned to activity while still experiencing concussion symptoms may also be at greater risk for persistent symptoms, according to Putukian.

“There are several athletes who still do not report their injury whether it is because they do not want to be pulled or if they know that if they report that they have a concussion they will be out for a few days, at least, if not a week. Those individuals who stay in and do not report their concussion until later are potentially those more likely to then have persisting symptoms,” Putukian said.

Use of safety equipment

Despite the availability of safety equipment for athletes, such as helmets, headgear and mouth guards, primary prevention of sport-related concussions is not completely possible, according to the guidance. Sutton noted playing sports safely and by the rules is more likely to prevent sport-related concussions compared with the use of more safety equipment.

“Playing sports safely and abiding by the rules is one of the best ways to prevent concussions and having coaches educate the athletes in practice in terms of appropriate defensive plays and how to not injure yourself while tackling or checking. I think that is critical,” Sutton said. “So, understand the rules of the game, because I think a lot of people want to abide by, ‘Let’s just get more equipment and that will be more protective,’ but that is not the answer.”

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