Consensus Statement On Concussion In Sport: The 3rd .

Downloaded from bjsm.bmj.com on 14 May 2009Supplementdisturbance rather than a structuralinjury.4. Concussion results in a graded set ofclinical symptoms that may or may notinvolve loss of consciousness. Resolutionof the clinical and cognitive symptomstypically follows a sequential course;however it is important to note that in asmall percentage of cases however, postconcussive symptoms may be prolonged.5. No abnormality on standard structuralneuroimaging studies is seen in concussion.1.2 Classification of concussionThere was unanimous agreement to abandon the simple versus complex terminologythat had been proposed in the Pragueagreement statement as the panel felt thatthe terminology itself did not fully describethe entities. The panel however unanimously retained the concept that themajority (80–90%) of concussions resolvein a short (7–10 day) period, although therecovery time frame may be longer inchildren and adolescents.22. Concussion evaluation2.1 Symptoms and signs of acute concussionThe panel agreed that the diagnosis ofacute concussion usually involves theassessment of a range of domains including clinical symptoms, physical signs,behaviour, balance, sleep and cognition.Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and whenconducting a pre-participation examination. The detailed clinical assessment ofconcussion is outlined in the SCAT2 form(see p 85).The suspected diagnosis of concussioncan include one or more of the followingclinical domains:a.Symptoms—somatic (eg, headache),cognitive (eg, feeling like in a fog)and/or emotional symptoms (eg, lability).b. Physical signs (eg, loss of consciousness, amnesia).c. Behavioural changes (eg, irritability).d. Cognitive impairment (eg, slowedreaction times).e. Sleep disturbance (eg, drowsiness).If any one or more of these componentsis present, a concussion should be suspected and the appropriate managementstrategy instituted.2.2 On-field or sideline evaluation of acuteconcussionWhen a player shows any features of aconcussion:a.The player should be medically evaluated onsite using standard emergency management principles andparticular attention should be givento excluding a cervical spine injury.b. The appropriate disposition of theplayer must be determined by thetreating healthcare provider in atimely manner. If no healthcare provider is available, the player should besafely removed from practice or playand urgent referral to a physicianarranged.c. Once the first aid issues are addressed,then an assessment of the concussiveinjury should be made using theSCAT2 or other similar tool.d. The player should not be left alonefollowing the injury and serial monitoring for deterioration is essentialover the initial few hours followinginjury.e. A player with diagnosed concussionshould not be allowed to return to playon the day of injury. Occasionally inadult athletes, there may be return toplay on the same day as the injury. SeeSection 4.2.It was unanimously agreed that sufficient time for assessment and adequatefacilities should be provided for theappropriate medical assessment both onand off the field for all injured athletes. Insome sports this may require rule changeto allow an off-field medical assessmentto occur without affecting the flow of thegame or unduly penalising the injuredplayer’s team.Sideline evaluation of cognitive function is an essential component in theassessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have beenshown to be practical and effective. Suchtests include the Maddocks questions3 4and the Standardized Assessment ofConcussion (SAC).5–7 It is worth notingthat standard orientation questions (eg,time, place, person) have been shown tobe unreliable in the sporting situationwhen compared with memory assessment.4 8 It is recognised, however, thatabbreviated testing paradigmsaredesigned for rapid concussion screeningon the sidelines and are not meant toreplace comprehensive neuropsychologicaltesting which is sensitive to detect subtledeficits that may exist beyond the acuteepisode; nor should they be used as astand-alone tool for the ongoing management of sports concussions.It should also be recognised that theappearance of symptoms might beBr J Sports Med 2009;43(Suppl I):i76–i84. doi:10.1136/bjsm.2009.058248delayed several hours following a concussive episode.2.3 Evaluation in emergency room or officeby medical personnelAn athlete with concussion may beevaluated in the emergency room ordoctor’s office as a point of first contactfollowing injury or may have beenreferred from another care provider. Inaddition to the points outlined above, thekey features of this exam should encompass:a.A medical assessment including acomprehensive history, and detailedneurological examination including athorough assessment of mental status, cognitive functioning and gaitand balance.b. A determination of the clinical statusof the patient including whetherthere has been improvement or deterioration since the time of injury. Thismay involve seeking additional information from parents, coaches, teammates and eyewitnesses to the injury.c. A determination of the need foremergent neuroimaging in order toexclude a more severe brain injuryinvolving a structural abnormalityIn large part, these points above areincluded in the SCAT2 assessment, whichforms part of the Zurich consensus statement.3. Concussion investigationsA range of additional investigations maybe utilised to assist in the diagnosis and/orexclusion of injury. These include thefollowing.3.1 NeuroimagingIt was recognised by the panellists thatconventional structural neuroimaging isnormal in concussive injury. Given thatcaveat, the following suggestions aremade: brain CT (or where available, MRbrain scan) contributes little to concussion evaluation but should be employedwhenever suspicion of an intracerebralstructural lesion exists. Examples of suchsituations may include prolonged disturbance of conscious state, focal neurological deficit or worsening symptoms.Newer structural MRI modalitiesincluding gradient echo, perfusion anddiffusion imaging have greater sensitivityfor structural abnormalities. However, thelack of published studies as well as absentpre-injury neuroimaging data limits theusefulness of this approach in clinicalmanagement at the present time. Ini77

Downloaded from bjsm.bmj.com on 14 May 2009Supplementaddition, the predictive value of variousMR abnormalities that may be incidentally discovered is not established at thepresent time.Other imaging modalities such as functional MRI (fMRI) show activation patterns that correlate with symptomseverity and recovery in concussion.9–13While not part of routine assessment atthe present time, they nevertheless provide additional insight to pathophysiological mechanisms. Alternative imagingtechnologies (eg, positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functionalconnectivity), while demonstrating somecompelling findings, are still at earlystages of development and cannot berecommended other than in a researchsetting.3.2 Objective balance assessmentPublished studies, using both sophisticated force plate technology and lesssophisticated clinical balance tests (eg,balance error scoring system (BESS)), haveidentified postural stability deficits lastingapproximately 72 hours following sportrelated concussion. It appears that postural stability testing provides a usefultool for objectively assessing the motordomain of neurological functioning, andshould be considered a reliable and validaddition to the assessment of athletessuffering from concussion, particularlywhere symptoms or signs indicate abalance component.14–203.3 Neuropsychological assessmentThe application of neuropsychological(NP) testing in concussion has beenshown to be of clinical value and continues to contribute significant informationinconcussionevaluation.21–26Although in most case cognitive recoverylargely overlaps with the time course ofsymptom recovery, it has been demonstrated that cognitive recovery may occasionally precede or more commonlyfollow clinical symptom resolution, suggesting that the assessment of cognitivefunction should be an important component in any return to play protocol.27 28 Itmust be emphasised however, that NPassessment should not be the sole basis ofmanagement decisions; rather it should beseen as an aid to the clinical decisionmaking process in conjunction with arange of clinical domains and investigational results.Neuropsychologists are in the bestposition to interpret NP tests by virtueof their background and training.i78However, there may be situations whereneuropsychologists are not available andother medical professionals may performor interpret NP screening tests. Theultimate return to play decision shouldremain a medical one in which a multidisciplinary approach, when possible, hasbeen taken. In the absence of NP andother (eg, formal balance assessment)testing, a more conservative return toplay approach may be appropriate.In the majority of cases, NP testing willbe used to assist return to play decisionsand will not be done until patient issymptom free.29 30 There may be situations (eg, child and adolescent athletes)where testing may be performed earlywhile the patient is still symptomatic toassist in determining management. Thiswill normally be best determined inconsultation with a trained neuropsychologist.31 323.4 Genetic testingThe significance of apolipoprotein (Apo) E4,ApoE promotor gene, tau polymerase andother genetic markers in the managementof sports concussion risk or injury outcomeis unclear at this time.33 34 Evidence fromhuman and animal studies in more severetraumatic brain injury shows induction of avariety of genetic and cytokine factors, suchas: insulin-like growth factor-1 (IGF-1), IGFbinding protein-2, fibroblast growth factor,Cu–Zn superoxide dismutase, superoxidedismutase-1 (SOD-1), nerve growth factor,glial fibrillary acidic protein (GFAP) and S100. Whether such factors are affected insporting concussion is not known at thisstage.35–423.5 Experimental concussion assessmentmodalitiesDifferent electrophysiological recordingtechniques (eg, evoked response potential(ERP), cortical magnetic stimulation andelectroencephalography) have demonstrated reproducible abnormalities in thepost-concussive state; however not allstudies reliably differentiated concussedathletes from controls.43–49 The clinicalsignificance of these changes remains tobe established.In addition, biochemical serum andcerebral spinal fluid markers of braininjury (including S-100, neuron specificenolase (NSE), myelin basic protein(MBP), GFAP, tau, etc) have been proposed as means by which cellular damagemay be detected if present.50–56 There iscurrently insufficient evidence however,to justify the routine use of these biomarkers clinically.4. Concussion managementThe cornerstone of concussion management is physical and cognitive rest untilsymptoms resolve and then a gradedprogramme of exertion prior to medicalclearance and return to play. The recoveryand outcome of this injury may bemodified by a number of factors thatmay require more sophisticated management strategies. These are outlined in thesection on modifiers below.As described above, the majority ofinjuries will recover spontaneously overseveral days. In these situations, it isexpected that an athlete will proceedprogressively through a stepwise returnto play strategy.57 During this period ofrecovery while symptomatic, following aninjury, it is important to emphasise to theathlete that physical and cognitive rest isrequired. Activities that require concentration and attention (eg, scholastic work,videogames, text messaging, etc) mayexacerbate symptoms and possibly delayrecovery. In such cases, apart from limiting relevant physical and cognitive activities (and other risk-taking opportunitiesfor re-injury) while symptomatic, nofurther intervention is required duringthe period of recovery and the athletetypically resumes sport without furtherproblem.4.1 Graduated return to play protocolReturn to play protocol following aconcussion follows a stepwise process asoutlined in table 1.With this stepwise progression, theathlete should continue to proceed tothe next level if asymptomatic at thecurrent level. Generally each step shouldtake 24 hours so that an athlete wouldtake approximately one week to proceedthrough the full rehabilitation protocolonce they are asymptomatic at rest andwith provocative exercise. If any postconcussion symptoms occur while in thestepwise programme, the patient shoulddrop back to the previous asymptomaticlevel and try to progress again after afurther 24-hour period of rest has passed.4.2 Same day RTPWith adult athletes, in some settings,where there are team physicians experienced in concussion management andsufficient resources (eg, access to neuropsychologists, consultants, neuroimaging,etc) as well as access to immediate (ie,sideline)neurocognitiveassessment,return to play management may be morerapid. The RTP strategy must still followthe same basic management principles,Br J Sports Med 2009;43(Suppl I):i76–i84. doi:10.1136/bjsm.2009.058248

Downloaded from bjsm.bmj.com on 14 May 2009SupplementTable 1 Graduated return to play protocolRehabilitation stageFunctional exercise at each stage of rehabilitation1. No activityComplete physical and cognitive rest2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity,70% maximum predicted heart rateNo resistance training3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No headimpact activities4. Non-contact trainingProgression to more complex training drills, eg passing drillsdrillsin football and ice hockeyMay start progressive resistance training)5. Full contact practice Following medical clearance participate in normal trainingactivities6. Return to playObjective of each stageRecoveryIncrease heart rateAdd movementExercise, coordination, andcognitive loadRestore confidence andassess functional skills bycoaching staffNormal game playnamely full clinical and cognitive recoverybefore consideration of return to play.This approach is supported by publishedguidelines, such as the American Academyof Neurology, US Team PhysicianConsensus Statement, and US NationalAthletic Trainers Association PositionStatement.58–60 This issue was extensivelydiscussed by the consensus panellists andit was acknowledged that there is evidence that some professional Americanfootball players are able to RTP morequickly, with even same day RTP supported by National Football League studies without a risk of recurrence orsequelae.61 There are data however,demonstrating that at the collegiate andhigh school level, athletes allowed to RTPon the same day may demonstrate NPdeficits post-injury that may not beevident on the sidelines and are morelikely to have delayed onset of symptoms.62–68 It should be emphasised however, that the young (,18) elite athleteshould be treated more conservativelyeven though the resources may be thesame as for an older professional athlete(see Section 6.1).4.3 Psychological management and mentalhealth issuesIn addition, psychological approachesmay have potential application in thisinjury, particularly with the modifierslisted below.69 70 Caregivers are alsoencouraged to evaluate the concussedathlete for affective symptoms such asdepression, as these symptoms may becommon in concussed athletes.574.4 The role of pharmacological therapyPharmacological therapy in sports concussion may be applied in two distinctsituations. The first of these situations isthe management of specific prolongedsymptoms (eg, sleep disturbance, anxiety,etc). The second situation is where drugtherapy is used to modify the underlyingpathophysiology of the condition withthe aim of shortening the duration of theconcussion symptoms.71 In broad terms,this approach to management should onlybe considered by clinicians experienced inconcussion management.An important consideration in RTP isthat concussed athletes should not onlybe symptom-free but also should not betaking any pharmacological agents/medications that may mask or modify thesymptoms of concussion. Where antidepressant therapy may be commencedduring the management of a concussion,the decision to return to play while stillon such medication must be consideredcarefully by the treating clinician.4.5 The role of pre-participation concussionevaluationRecognising the importance of a concussion history, and appreciating the factthat many athletes will not recognise allthe concussions they may have suffered inthe past, a detailed concussion history isof value.72–75 Such a history may preidentify athletes that fit into a high riskcategory and provides an opportunity forthe healthcare provider to educate theathlete in regard to the significance ofconcussive injury. A structured concussion history should include specific questions as to previous symptoms of aconcussion; not just the perceived numberof past concussions. It is also worthnoting that dependence on the recall ofconcussive injuries by teammates or coaches has been shown to be unreliable.72The clinical history should also includeinformation about all previous head, faceor cervical spine injuries as these may alsohave clinical relevance. It is worth emphasising that in the setting of maxillofacialand cervical spine injuries, coexistentconcussive injuries may be missed unlessspecifically assessed. Questions pertaining to disproportionate impact versusBr J Sports Med 2009;43(Suppl I):i76–i84. doi:10.1136/bjsm.2009.058248symptom severity matching may alertthe clinician to a progressively increasingvulnerability to injury. As part of theclinical history it is advised that detailsregarding protective equipment employedat time of injury be sought, for bothrecent and remote injuries. A comprehensive pre-participation concussion evaluation allows for modification andoptimisation of protective behaviour andan opportunity for education.5. Modifying factors in concussionmanagementThe consensus panel agreed that a rangeof ‘modifying’ factors may influence theinvestigation and management of concussion and in some cases, may predict thepotential for prolonged or persistentsymptoms. These modifiers would alsobe important to consider in a detailedconcussion history and are outlined inTable 2.In this setting, there may be additionalmanagement considerations beyond simple RTP advice. There may be a moreimportant role for additional investigations, including formal NP testing, balance assessment and neuroimaging. It isenvisioned that athletes with such modifying features would be managed in amultidisciplinary manner coordinated bya physician with specific expertise in themanagement of concussive injury.The role of female gender as a possiblemodifier in the management of concussion was discussed at length by the panel.There was not unanimous agreement thatthe current published research evidence isconclusive that this should be included asa modifying factor, although it wasaccepted that gender may be a risk factorfor injury and/or influence injury severity.76–785.1 The significance of loss of consciousness(LOC)In the overall management of moderate tosevere traumatic brain injury, duration ofLOC is an acknowledged predictor ofoutcome.79 While published findings inconcussion describe LOC associated withspecific early cognitive deficits it has notbeen noted as a measure of injuryseverity.80 81 Consensus discussion determined that prolonged (.1 minute duration) LOC would be considered as a factorthat may modify management.5.2 The significance of amnesia and othersymptomsThere is renewed interest in the role ofpost-traumatic amnesia and its role as ai79

Downloaded from bjsm.bmj.com on 14 May 2009SupplementTable 2 Concussion modifiersFactorsModifierSymptomsNumberDuration (.10 days)SeverityProlonged loss of consciousness (.1 min), amnesiaConcussive convulsionsFrequency—repeated concussions over timeTiming—injuries close together in time‘‘Recency’’—recent concussion or traumatic brain injuryRepeated concussions occurring with progressively less impact force or slower recoveryafter each successive concussionChild and adolescent (,18 years old)Migraine, depression or other mental health disorders, attention deficit hyperactivitydisorder, learning disabilities, sleep disordersPsychoactive drugs, anticoagulantsDangerous style of playHigh risk activity, contact and collision sport, high sporting levelSignsSequelaeTemporalThresholdAgeCo- and pre-morbiditiesMedicationBehaviourSportsurrogate measure of injury severity.67 82 83Published evidence suggests that thenature, burden and duration of the clinicalpost-concussive symptoms may be moreimportant than the presence or durationof amnesia alone.80 84 85 Further it must benoted that retrograde amnesia varies withthe time of measurement post-injury andhence is poorly reflective of injury severity.86 875.3 Motor and convulsive phenomenaA variety of immediate motor phenomena(eg, tonic posturing) or convulsive movements may accompany a concussion.Although dramatic, these clinical featuresare generally benign and require nospecific management beyond the standardtreatment of the underlying concussiveinjury.88 895.4 DepressionMental health issues (such as depression)have been reported as a long-term consequence of traumatic brain injury,including sports related concussion.Neuroimaging studies using fMRI suggestthat a depressed mood following concussion may reflect an underlying pathophysiological abnormality consistent with alimbic-frontal model of depression.52 90–1006. Special populations6.1 The child and adolescent athleteThere was unanimous agreement by thepanel that the evaluation and management recommendations contained hereincould be applied to children and adolescents down to the age of 10 years. Belowthat age children report different concussion symptoms from adults and wouldrequire age appropriate symptom checklists as a component of assessment. Anadditional consideration in assessing thei80child or adolescent athlete with a concussion is that in the clinical evaluation bythe healthcare professional there may bethe need to include both patient andparent input as well as teacher and schoolinput when appropriate.101–107The decision to use NP testing isbroadly the same as the adult assessmentparadigm. However, timing of testingmay differ in order to assist planning inschool and home management (and maybe performed while the patient is stillsymptomatic). If cognitive testing isperformed, it must be developmentallysensitive until the late teen years due tothe ongoing cognitive maturation thatoccurs during this period which, in turn,makes the utility of comparison to eitherthe person’s own baseline performance orto population norms limited.20 In this agegroup it is more important to consider theuse of trained neuropsychologists tointerpret assessment data, particularly inchildren with learning disorders and/orattention deficit hyperactivity disorder(ADHD) who may need more sophisticated assessment strategies.31 32 101The panel strongly endorsed the viewthat children should not be returned topractice or play until clinically completelysymptom-free, which may require alonger time frame th

Furthermore, a detailed concussion his-tory is an important part of the evalua-tion both in the injured athlete and when conducting a pre-participation examina-tion. The detailed clinical assessment of concussion is outlined in the SCAT2 form (see p 85). The suspected diagnosis of concussion can include one or more of the following clinical .