Sports Medicine Research: In the Lab & In the Field: Comparison of Three New Concussion Guidelines (Sports Med Res)


Wednesday, September 11, 2013

Comparison of Three New Concussion Guidelines

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

Related Posts:

West TA, & Marion DW (2013). Current Recommendations for the Diagnosis and Treatment of Concussion in Sport: A Comparison of Three New Guidelines. Journal of Neurotrauma PMID: 23879529


Lauren said...

As the summary states, it is very reassuring that all three position statements ultimately reach the same conclusions. What differs is their methodology of getting to that conclusion. The bottom line is the we still simply don't know enough about concussions. Hopefully, as the research continues to come out and technology continues to advance we will have better methods of diagnosing and treating concussions. Until then, though, it is difficult to draw any other conclusions other than the one all three have conceded on above. As for which consensus statement I use most, the Zurich statements have generally been my go-to regarding concussion policy. To me, they are the most well known and also the most taught in ATEP programs. Most people I know and work with are familiar with the Zurich guidelines.

Catherine LeBlanc said...

I agree with Lauren in that the Zurich statements are the most widely known of the three consensus statements. It is reassuring that despite the differences in methodology, there more similarities than differences between the three guidelines. The difficulty with these guidelines is that cannot be applied to more complex concussion cases, and therefore there is a wide amount of variability for healthcare providers when determining which is the best course of treatment. One advancement in these guidelines is the inclusion of return-to-school prior to returning to any sports related activities. Though a gold-standard for proper diagnosis and return to play for concussions are still needed, the research for concussion management is going in a positive direction.

Amanda Brown said...

I agree with Lauren that we still do not know enough about concussions. There is still a lot of research that needs to be done before we will be able to reach one general concensus. With that said, I believe that there also needs to be a lot more concussion education for coaches, athletes, parents, and the general public. Most people do not understand that their brain is injured and your brain is the most the important part of your body. Whenever an athlete has a concussion I try to explain the importance of cognitive rest because you only get one brain. I also follow the Zurich guidelines. I think it is very important that the athlete is 100% symptom free before returning to play and these guidelines reinforce that idea as well implement a gradual return to activity.

Andrew Albano Jr said...

Arguably still in it's infancy, the field of concussion evaluation and management has made significant strides in a relatively short period of time. Building on the experiences and opinions of our medical colleagues (consensus statements), the diagnostic and management considerations of TBI/concussion have improved. Moving forward, we as a collective medical community, will need to continually delineate the best diagnostic criteria and treatment considerations to provide optimal care for our patients.

Catherine Donahue said...

In regards to what return to play protocols I find most beneficial as an athletic trainer: I feel that this is an area that highlights the need for knowing your athletes.Athletes are always eager to get back to play and often times will do so at the price of their health. But knowing your athlete goes a long way in being able to determine if they are struggling through phases of the return to play or if they are trying to hide symptoms. Another practice that has helped is making sure the athlete is also symptom free in the classroom before I start their return to play. I have found more often than not that a student-athlete is still having mild symptoms with classroom activities even when they claim to be ready to start a return to play.

Jeffrey Driban said...

Catherine, I agree. Those are great points. Also a gradual progression to return to play can help you pick up on some subtle changes or help the athlete realize they might not be ready.

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