Updated Concussion Recommendations for Team Physicians

Elizabeth Millard

June 24, 2020

As awareness of sports-related concussion grows, diagnosis and treatment recommendations are changing.

That means patients with an excruciating headache no longer have to spend hours in a dark room, trying not to move. And physicians no longer rely exclusively on imaging, but also take an extensive health history so that they understand the stressors that were present in the patient before an injury.

An updated consensus statement for the team physician aimed at diagnosis, injury management, recovery, and return-to-play strategies — particularly for young athletes — was presented at the virtual American College of Sports Medicine 2020 Annual Meeting.

There are several key takeaways from this round of recommendations, said Stanley Herring, MD, from UW Medicine in Seattle, who is chair of the group of practicing team physicians who developed recommendations for the management of sports-related concussions in 2005 and then updated them in 2011.

One of the most important takeaways is that the diagnosis of sport-related concussion remains a challenge because of the nonspecific symptoms and the lack of objective biomarkers, Herring explained during his presentation. That means that diagnosis should lean heavily on thorough exams that take into account factors such as history of depression and anxiety, previous struggles with migraines, family history of mood disorders, and social stressors, all of which have been associated with slower recovery.

"You have to look at what the athlete is bringing to the concussion," Herring told Medscape Medical News. "There may be a high burden of risk coming into the injury that will affect how long symptoms will be present. Providers are encouraged to look for signs like blurred vision and dizziness, for example. And while that's important, it's also crucial to talk about underlying mental health issues that could extend symptom prevalence."

Although recovery time will vary with age, these are modifying factors that team physicians, coaches, and care providers can consider, especially if disabling symptoms persist.

Another major recommendation is to eliminate the practice of "cocooning," in which a person with a concussion sits in a dark room, sometimes for several days, in the belief that bed rest and stillness helps the brain recover faster. That strategy has been on the way out over the past few years, Herring said, and should be discouraged because the opposite tends to be true — returning to light activity, even in the days after concussion, might help shorten recovery timeframes.

Charting a Path Forward

Because there is no single test to definitively confirm the presence or history of a concussion, this consensus statement is helpful to disseminate best-practice principles globally, said John Hatzenbuehler, MD, from St. Luke's Family Medicine in Hailey, Idaho.

"Concussions involve complexity of diagnosis and management, and they affect patients not only on a cellular, physical level, but also at an emotional and psychological level," he told Medscape Medical News. "Being able to take all the new information uncovered through scientific study and turn it into guidelines is the best way to keep everyone up to date in a way that can benefit patients."

But concussions often seem like snowflakes; each is unique in terms of symptoms, recovery time, and treatment, he explained. There is no one-size-fits-all approach because each patient has distinctive physical, genetic, psychological, and social characteristics.

Since the 2011 update was released, there has been more emphasis on the need to recognize the signs of concussion and to remove athletes from play, said Hatzenbuehler, who was not involved in the development of the recommendations.

"No longer do we consider playing with your 'bell rung' a sign of toughness," he added. "This is a good thing, because it means there's been a change around education and awareness."

Laws have been passed in all states that cover sports-related concussion, Herring reported during his presentation. Most of those require that young athletes be removed from play if they have concussion symptoms and that they be evaluated by a provider trained in concussion management before they can return to play.

This is a huge change from just a decade ago, Hatzenbuehler said.

As concussion research keeps uncovering new facets of diagnosis and treatment, both Herring and Hatzenbuehler are confident that momentum will fuel progress in our understanding of the traumatic brain injury, and that it will be taken into account in the next consensus-statement update.

American College of Sports Medicine (ACSM) 2020 Annual Meeting.

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