“When in doubt, sit them out” is a phrase I have used innumerable times when speaking to coaches, parents, and healthcare providers about concussions. This concept errs on the side of caution when managing head injuries in athletes and non-athletes of all ages. The recent wave of scientific research on concussion has generated as many new questions as answers about the diagnosis, management, and long-term outcomes involved with the “complex pathophysiologic process affecting the brain induced by traumatic biomechanical forces.”1 The need for high-quality research can be seen in the fact that the vast majority of current recommendations and position statements are based on level C evidence (expert consensus). The specialties of sports medicine, neurology, neurosurgery, and neuropsychology have come together to provide current recommendations and to encourage the practitioners within those specialties to continue to advance the available research on all facets of the disease. These groups must continue to cooperate in this effort.
Research on concussion has received a great deal of press lately. When more than 4,500 former players sued the National Football League for trauma endured as a result of sport-induced concussions, the league made international news for its controversial settlement of $765 million. The league's continued attention to the issue, as well as financial support for research, will become vital if scientific advancement in this area is to continue. This is especially true with the decrease in available public funding for research.
Legislators have increasingly become interested in the issue of concussion as well. To date, 49 of the 50 states and the District of Columbia have enacted some form of sports concussion legislation, although the content of these laws varies greatly (Mississippi has brought bills before both the house and senate, but none have passed).2,3
Even with the need for further insight and the lack of high-level evidence, providers are asked to manage concussions on a daily basis. That comes with a great deal of responsibility. Best practices suggest that anyone who may have sustained a concussion should refrain from returning to an athletic event that day. In addition, patients should avoid contact activity until all symptoms completely resolve. A concussion should be suspected in anyone who has been subjected to a traumatic force and demonstrates
- physical symptoms, including headache, head pressure, neck pain, nausea or vomiting, dizziness, blurred vision, balance problems, photo- or phonophobia, fatigue, or drowsiness
- cognitive dysfunction, such as feeling slowed down, feeling in a fog, not feeling “right,” difficulty with concentration or memory, or confusion
- emotional symptoms including irritability, sadness, anxiety, nervousness, anger
- sleep disturbance, including trouble falling or staying asleep.4
Patients do not have to lose consciousness in order to be diagnosed with a concussion. Tools such as the Sport Concussion Assessment Tool, 3rd edition (SCAT3), Child SCAT3, or the Sport Concussion Office Assessment Tool (SCOAT) may be used to assist in the recognition and diagnosis of this condition and also can help guide a patient's return to activity.4–6 Once a concussion is diagnosed, the provider is tasked with determining when the athlete may return to learning, driving, and physical activity (both non-contact and contact).
As noted previously, no solid evidence is available to drive these decisions. However, physical and brain rest generally are emphasized during the early stages of the injury. Regardless of the time course of symptoms, an incremental return to mental and physical activity also is suggested.1,7,8 Should symptoms return or worsen, patients should be advised to cease advancement in mental and physical activities. In general, more conservative management with younger patients is appropriate. During this time, academic accommodations may be needed for the student athlete. The ultimate decision to return an athlete to a contact sport must be made cautiously and only after ensuring that the athlete has remained symptom-free through the appropriate progressions.
As healthcare providers, we also have a responsibility to stay abreast on emerging concussion research. Too often, we rely exclusively on the Internet. This month's online-only article “Original Research: Evaluating the quality of online information about concussions” investigates the content of multiple websites that provide information on concussions. The authors conclude that information available online varies in completeness and quality, which definitely raises concerns. I would strongly recommend that any provider who may manage concussion, no matter how rarely, become familiar with the position statements of the American Medical Society for Sports Medicine as well as the Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich.1,8
Like much in medicine, concussion science is still emerging. And until the time when we have higher levels of evidence and research can further guide our management, there is only one safe protocol: When in doubt, sit them out.
1. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med
3. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus
. 2012;33(6):E11: 1–9.
4. SCAT3. Br J Sports Med
5. Child SCAT3. Br J Sports Med
7. Master CL, Gioia GA, Leddy JJ, Grady MF. Importance of ‘return-to-learn’ in pediatric and adolescent concussion. Pediatr Ann
8. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med