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doi: 10.1097/01.NT.0000392765.88176.b1
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New AAN Position Paper on Sports Concussion Emphasizes Five Critical Procedures: Updated Practice Parameter Slated for Late 2011

Wesolowski, Kierstin

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ARTICLE IN BRIEF

The AAN position statement on sports concussion emphasizes the execution of five critical procedures if a player is suspected of sustaining a concussion during play – potentially reducing the number of debilitating and life-threatening injuries that can be caused by untreated concussions.

Concussion and its associated risks have been thrust into the national spotlight as sport stories about concussed athletes make front page news, and the National Football League (NFL) revises its policies to institute more severe penalties for injury-inducing hits on the field. Meanwhile in Washington, lawmakers have teamed up with concussion experts to pass legislation on national return-to-play guidelines.

In response to growing public awareness and mounting urgency regarding the dangers associated with concussion, the AAN released a position statement on sports concussion management on Nov. 1. The position statement emphasizes the execution of five critical procedures if a player is suspected of sustaining a concussion during play – potentially reducing the number of debilitating and life-threatening injuries that can be caused by untreated concussions. (See Sidebar “AAN Position Statement on Sports Concussion Management.”)

The AAN released the practice position statement now due to the urgent need for updated national guidelines that ensure the health and safety of all athletes, said Jeffrey Kutcher, MD, director of Michigan Neurosport at the University of Michigan and chair of the AAN Sports Neurology Section. The AAN is also updating its 1997 practice parameter on concussion management; the updated parameter is slated for release in late 2011.

“We wanted to release a position statement that at least addressed the concept that the 1997 document shouldn't be followed to the letter, and that people should be managing concussions individually and not as described in that document,” said Dr. Kutcher.

Neurology Today reached out to leading experts in sports concussion and athletic organizations for their reaction to the AAN's position statement and ideas on how to reduce the prevalence of sports concussions.

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EXPERTS' REACTIONS

DR. JEFFREY KUTCHER ...
DR. JEFFREY KUTCHER ...
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Paul Echlin, MD, a sports medicine specialist with AIM Health Group Family Medicine in London, Ontario, Canada, calls each one of the AAN recommendations “spot on.” Dr. Echlin and colleagues led a study on direct independent physician diagnosed concussion prevalence in Canadian hockey players, released the same day as the position statement. (See sidebar “Concussion Incidence in Canadian Junior Ice Hockey Teams”)

“The only thing to add would be that the certified athletic trainer should have a direct connection to a qualified physician” who could be easily contacted if the trainer observes and identifies a probable concussion during play, he said in a telephone interview with Neurology Today. “The athletic trainer is an important and skilled part of the medical team necessary for initial concussion identification, due to the fact that a physician with concussion expertise may not be at each game. The athletic trainer isn't qualified to make the diagnosis or allow the return to play, and must work with the physician for the benefit of the athlete.”

Stanley Herring, MD, co-medical director of the Seattle Sports Concussion Program and clinical professor at the University of Washington, said that although he's happy the AAN has taken an interest in the issues surrounding concussion management, the recommendation to have a certified trainer at every sporting event isn't realistic given budgetary issues affecting many schools.

THE NUMBER OF EMERGE...
THE NUMBER OF EMERGE...
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“This specific recommendation shouldn't act as a paralytic that stops people from participating in sports, because sports participation has many benefits,” added Dr. Herring, who is chairman of the NFL Subcommittee on Education and Advocacy, a member of the league's Head, Neck, and Spine Committee, and a team physician for the Seattle Seahawks and the Seattle Mariners.

Dr. Kutcher acknowledged that the position statement represents the AAN's optimal goals, and that some schools may lack the resources to have a trainer at every game. In those particular instances, Dr. Kutcher hopes school officials take into careful consideration whether it's a priority to have contact sports at the school.

“If it is, then they should seek out ways to further educate those that are around during the event, such as the coaches, parents, athletes, the school nurse, or whoever else might be in that environment,” he said. “At the very least, there's a huge gap in education that needs to be filled in.”

Dr. Echlin agrees that improving educational courses on concussion management for volunteers at sporting events is a crucial necessity. He suggested that involved parents, coaches, referees, and team executives participate and pass mandatory on-going concussion-specific education classes to raise the level of education concerning this injury.

Neurology Today also contacted representatives of the National Collegiate Athletic Association (NCAA), who declined to be interviewed, but sent a statement prepared by NCAA Director of Health and Safety David Klossner, PhD.

“The NCAA appreciates the leadership the AAN is providing within its position statement on concussion management in sports,” Dr. Klossner wrote in an e-mail to Neurology Today. “These recommendations fit well with legislation and policies adopted by the NCAA. Recognition, removal, treatment, and proper return-to-play under the supervision of a physician and their medical staff are paramount to managing athletes with sports-related concussions.”

The National Federation of High School Leagues (NFHS) assistant director, Bob Colgate, stated in response to a request for an interview that the NFHS doesn't provide commentary on position statements they didn't develop.

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COOPERATIVE COALITION

The best way to address the high incidence rate and misunderstanding about the nature of concussion is to establish a cooperative coalition comprised of multiple organizations and experts, said Dr. Echlin. “That's one of the ways to effect change because you have to overcome the inertia of people who don't understand this injury,” he said.

Dr. Herring agreed that the lack of understanding regarding the seriousness of concussive injury is a major obstacle that proponents of sports concussion management face. An active advocate for return-to-play laws on both the state and national level, Dr. Herring believes that a combination of both education and legislation will be the most effective in increasing awareness. (See “Capitol Hill Lawmakers Tackle Football Concussions in School Athletes: Issue Gains Momentum with Media Attention to Injuries” in the Oct. 21 issue of Neurology Today.)

“By making it law driven, coaches cannot make the call of returning a player to play, and they have expressed relief at not having to assume responsibility for that decision,” said Dr. Herring. “Also, an effect of the legislative effort to raise awareness about the consequences of concussion has been our observation that athletes are feeling more comfortable saying they're not okay to play.”

He noted that concussion is a public health issue that could reflect a cultural shift – much in the same way, for example, as the awareness to use a seatbelt while driving.

“The real change is going to come from grassroots [efforts], when the coaches, therapists, and physicians allow the player to directly report their injury and get evaluated by a trained physician that deals with sports concussion,” said Dr. Echlin. “With an international coalition, it makes it much easier to overcome [this issue], even though it's a large inertia to overcome, I think we can do it.”

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CONCUSSION INCIDENCE IN CANADIAN JUNIOR ICE HOCKEY TEAMS

On Nov. 1, Paul Echlin, MD, sports medicine specialist with AIM Health Group Family Medicine in London, Ontario, Canada, and colleagues released a study and an accompanying editorial in the journal Neurosurgical Focus on direct independent physician diagnosed incidence of concussion in two junior hockey teams in Canada. During 52-physician observed hockey games, investigators recorded the number of concussions sustained by 67 players. Below are some of the study's significant findings.

* Twenty-one concussions were either physician observed or self-reported during the 52 games, yielding an incidence of 21.5 concussions per 1,000 athlete exposures – 7 times higher than previously reported.

* Out of the 52 games, a concussion was diagnosed in 19 games (36.5 percent).

* Seventeen players sustained a concussion, and of those players, five (29 percent) sustained a second concussion. (One player had suffered his concussion during a game that wasn't physician observed. As a result, his initial concussion wasn't included in the total concussion count.)

* Five of the players diagnosed with concussion (24 percent) were directly involved in a fight immediately prior to their concussion diagnosis.

* Sixty-nine percent of the hits that were observed to cause the diagnosed concussion were to the head.

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AAN POSITION STATEMENT ON SPORTS CONCUSSION MANAGEMENT

AAN Position Statement on Sports Concussion Management

* Any athlete who appears to have sustained a concussion should immediately be removed from play, and the player should be evaluated by a doctor who has training in sports concussion.

* The athlete should not return to sports until all symptoms of concussion have alleviated.

* The athlete should abstain from sports until an evaluation has been performed by a doctor, who has training in sports concussion, and has been given clearance to return to play.

* A certified trainer should be present at every sporting event.

* Educational efforts on concussions should be emphasized to improve coaches’, players’, and parents’ understanding of the dangerous risks associated with concussion.

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REFERENCES:

AAN Position Statement on Sports Concussion http://bit.ly/cfKMXa
Bakhos LL, Lockhart GR, Myers R, et al. Emergency department visits for concussion in young athletes. Pediatrics 2010; E-pub 2010 Aug. 30.
Echlin PS, Tator CH, Cusimano MD, et al. A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates. Neurosurg Focus 2010; 29(5):E4
See Neurology Today's “School Sport Concussions Draw National Attention as More States Draft Return-to-Play Laws,” March 4, 2010; http://bit.ly/baAPeA
For more on Neurology Today's coverage on sports-related concussion, go to http://bit.ly/buAnRo

©2010 American Academy of Neurology

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