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