Current Recommendations for the Diagnosis and Treatment of Concussion in Sport: A Comparison of Three New Guidelines.
West TA, Marion DW. J Neurotrauma. 2013. ePub ahead of print: July 23, 2013 (doi:10.1089/neu.2013.3031).
Take-Home Message: Despite methodological differences, consensus statements from AMSSM, AAN, and 4th International Conference on Concussion in Sports reach similar broad conclusions about evaluating and treating concussions. Unfortunately, we still need more evidence to optimize our diagnostic approach and management strategies.
The increased incidence of sport-related concussion has raised public concern resulting in increased legislation and evaluations by medical providers. In an effort to minimize controversy and confusion, several organizations created position/consensus statements but there are subtle differences between them because they use different methods to reach consensus. To optimally treat our athletes, we need to understand when the statements agree and which statements use expert opinion compared with those that are primarily evidence-based. The authors of this article reviewed three recent publications for comparison and discussion: The American Medical Society for Sports Medicine (AMSSM) position statement: Concussion in Sport, The American Academy of Neurology (AAN) Summary of Evidence-based Guideline update: Evaluation and Management of Concussion in Sports and The Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. The authors of these guidelines represent physicians, athletic trainers, physical therapists, and other concussion consultants for all levels of sport. The AMSSM reviewed the available literature although the specific methodology was not included in the manuscript. The authors developed the AMSSM recommendations by combining data from the available literature with consensus/expert opinion and best practice. In contrast, the AAN performed a systematic review of all pertinent literature published from 1955 to June 2012. Their final recommendations were heavily data-driven and not based solely on consensus, usual practice, expert opinion, case-series, or meta-analyses. Lastly, the Consensus Statement from Zurich served as an update from three previous recommendations originally developed in 2001 with the last update completed in 2008. Recommendations were developed from a formal consensus process that utilized the organizational guidelines published by the US National Institutes of Health (NIH). Specific details of the literature review and development of the consensus statement were not available in the manuscript. The stated purpose of the AMSSM consensus statement and the 4th International Conference on Concussion in Sport are more similar to each other and different from the approach of the AAN. The AAN attempted to develop an entirely evidence-based approach for this topic. However, where evidence was lacking, the AMSSM and Zurich statements attempted to fill these gaps with expert opinion and extrapolation from limited studies.
Despite methodological difference, all three statements acknowledge that concussion symptoms arise from an alteration of brain function – not a structural abnormality. While there is no gold-standard diagnostic examination, the statements agree that a licensed health care provider, who is familiar with concussion signs and symptoms, should examine the patient, remove the patient from play if a concussion is suspected, and use a graded symptom/clinical checklist coupled with repeated exams to monitor changes in signs and/or symptoms. The groups agree that a patient with a suspected concussion should not return to play on the day of incident and that return to play should follow a graded, stepwise progression as dictated by signs/symptoms in the athletes. It is reassuring that the three statements, despite different methodologies, reach similar broad conclusions. Hopefully, in the future we will have more research to help us optimize our diagnostic approach, management considerations, and return-to-play protocol.
Questions for Discussion: Do you rely on one of the concussion position/consensus statements more than another? What return-to-play considerations do you find most beneficial in avoiding/preventing concussion?
Reviewed by: Jeffrey Driban