Return to play and risk of repeat concussion in collegiate football players: comparative analysis from the NCAA Concussion Study (1999–2001) and CARE Consortium (2014–2017)

McCrea M, Broglio S, McAllister T, Zhou W, Zhao S, Katz B, Kudela M, Harezlak J, Nelson L, Meier T, Marshall SW, Guskiewicz KM, On behalf of CARE Consortium Investigators. Br J Sports Med. 2019 [Epub ahead of print]

Take Home Message: College football players diagnosed with a concussion are being managed more conservatively with stricter return-to-play protocols, which may be related to a lower risk of repeat concussions during a season compared to 15 years ago.

Over the past 15 years, an increase in concussion awareness and research has to lead to new policies, rule changes in the sport, and enhanced concussion assessment and management protocols. Understanding how these changes influence outcomes, such as the risk of repeat concussion, may help support current policies and consensus recommendations. Hence, the authors compared data from two prospective cohorts to examine if injury management, return to play (RTP), and risk of repeated concussions among collegiate football players changed over 15 years. Specifically, the authors used data from the NCAA Concussion Study (1999–2001) and the Concussion Assessment, Research and Education (CARE) Consortium (2014–2017). The NCAA Concussion Study included 2,905 NCAA football players from 25 NCAA Division I, II and III universities from 1999 to 2001. Athletes that sustained a concussion (184 athletes) underwent clinical assessments immediately, 3 hours, and 1, 2, 3, 5, 7 and 90 days after injury. The CARE Consortium enrolled over 40,000 athletes at 30 NCAA Division I, II and III institutions since 2014. The CARE post-injury concussion assessment involved follow-up testing of athletes with a concussion (701 football athletes) at <6 hours, 24 to 48 hours, time of asymptomatic, the start of RTP protocol, unrestricted RTP, and 6 months after injury. Both studies collected detailed information on clinical recovery, management, RTP, and repeat concussion. Overall, compared to the NCAA Concussion study cohort, the CARE consortium athletes had a longer time from injury to the asymptomatic time point (~9 days vs ~3 days), symptom duration (6 days vs 2 days), total time for RTP after concussion (~16 days vs 7 days). The rate of within-season repeat concussion in the CARE Consortium (~4%; 27 athletes out of 701 athletes) was 41% lower than in the NCAA Concussion Study (~7%; 12 athletes out of 184 athletes). Finally, in the CARE Consortium, there was only one repeat concussion during the first 10 days after an initial injury while in contrast 11 of the 12 repeat concussions in the NCAA Study happened during those first 10 days.

The authors found a major shift in the clinical management of a sports-related concussion. CARE Consortium athletes were withheld from play nearly 10 days longer than the original NCAA cohort. Additionally, CARE athletes reported longer symptom recovery, which could be attributed to better sign and symptoms assessment or athlete recognition and knowledge of concussion signs and symptoms. Over 97% of CARE athletes had a symptom-free waiting period before starting an RTP protocol; in contrast, only ~ 60% of NCAA Concussion Study athletes had a symptom-free waiting period. This combination of lengthier recovery time and a more systematic implementation of an RTP protocol resulted in a more conservative approach to management compared with the original NCAA study. Furthermore, the extended recovery period could be associated with the 41% decline in the within-season repeated concussions. Future studies should evaluate the impact of concussion education and whether other medical teams in other sports are adopting a more conservative approach to concussion management. Currently, medical professionals should be aware of contemporary concussion recommendations and the evidence supporting these recommendations to provide proper concussion diagnosis and safe RTP.

Questions for Discussion: How long do your athletes take to recover following a concussion? Have you noticed the number of same season repeat concussions declined?

Written by: Jane McDevitt

Reviewed by: Jeffrey Driban

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