New Recommendations on Sport-Related Concussions

STRONGER METHODOLOGY The 5th International Consensus Statement on Concussion in Sport1 introduced several new recommendations that have direct and practical implications for the clinician. One of the new characteristics of the work of the Concussion in Sport Group is the methodology used and the 18 months of work that preceded the consensus conference itself.2 Twelve key questions were defined using a Delphi technique, and each of these questions led to a systematic review of the available evidence regarding each topic.2 As part of that methodology, a 2-day conference occurred and was followed by a 1-day consensus meeting with an extended group of multidisciplinary experts to summarize the evidence and discussion at the conference and achieve a consensus on proposed recommendations from each of these reviews. The output of this conference is summarized in the 5th International Consensus Statement on Concussion in Sport. PRACTICAL MESSAGES The 5th International Consensus Statement on Concussion in Sport includes a summary of the current literature in the area of sport-related concussion (SRC) that will affect how physicians, sport therapists, and other health care professionals can implement best practice in concussion prevention, detection, and management standpoint, ultimately facilitating a safe return to normal activities. This information can then be translated down to the field of play and clinical environments. However, most concussions that occur in sport and leisure environments do not have a dedicated sport therapist or physician on location. Thus, the Concussion Recognition Tool 5 (CRT5) was developed to assist parents, coaches, officials, and players to recognize when a concussion may have occurred and to give recommendations for removal from play and medical follow-up.3 For clinicians involved in the initial evaluation and management of concussion, this statement contains important information that can be implemented into their own unique clinical context, with some of the key messages summarized in Table 1. The Canadian Concussion Collaborative has also developed a comprehensive summary of key messages from the Berlin recommendations that is available in French and English.4TABLE 1.: Key New Messages From the Berlin Recommendations1The limited initial rest period (24-48 hours of cognitive and physical rest) followed by the use of the subsymptom threshold activity principle is an important new paradigm introduced by the 5th International Consensus Statement on Concussion in Sport.5 The statement recommends a graduated return to school (RTSc) and return to sport (RTSp) strategy that is individualized based on the clinical evolution of the athlete. The literature remains limited in terms of the timing of resolution of symptoms and reintroduction of sport-related activity.5 There is no 1 physiological marker of recovery that has been identified.5 Thus, the RTSp strategy creates a “buffer zone.”6 Although gradual RTSc and low risk physical activity can be introduced in a coordinated fashion, it is recommended that complete RTSc occurs before “returning to sport.”7,8 Accordingly, RTSc and RTSp can occur in a coordinated fashion, as proposed in Figure 1. Once an individual can complete activities of daily living without concussion-related symptoms, their health care professional can guide them through the RTSc strategy.7,8 The use of the subthreshold activity principle through the RTSp strategy is a topic of much discussion. Future evaluation to better understand how different interpretations of this subthreshold activity principle may affect outcomes after concussion and the associated physiological mechanisms is needed.Figure 1.: Basic considerations for the medical clearance decision.It remains important to recognize that if symptoms worsen or recur during any step of the RTSp or RTSc strategy, individuals should return to the previous step and medical clearance is required before proceeding to step 5 of RTSp.7,8 Clinicians should take into account that multiplayer sport-specific training drills involve a risk of unintentional collision although they are meant to be without contact. The literature regarding timing of concurrent progression of school in combination with low risk physical activities, including walking to and from school, is limited and is an area where future evaluation is needed to inform the optimal timing of such activities and the possibility to further use the subthreshold activity principle during the recovery process. REMAINING CHALLENGES In an ideal sport environment, access to onsite medical personnel and timely access to medical follow-up would be available in the event of a suspected concussion. However, these resources are often only available in higher level sporting environments and, in many settings, onsite medical personnel are not available. Thus, the CRT5 can be used by coaches, officials, parents, and players to identify when a concussion may have occurred. Processes may need to differ in remote or “grassroots” settings based on the available resources because access to medical follow-up may prove to be challenging. Research has the potential to document how leaders in school-based and community-based sport and recreation environments could be empowered to implement the best evidence into practice to facilitate safe and efficient management of concussions with consideration for available resources. Consideration for available resources also brings the following question: who can properly identify and safely manage a concussion? The consensus statement states that all suspected SRC should be “…assessed by a physician or licensed health care provider…” Being licensed to diagnose in any given jurisdiction is often proposed as an answer to that question (eg, doctors and nurse practitioners).9 However, it has also been suggested that more efficient and timely access to quality care for concussions could be achieved by sharing these responsibilities with a broader spectrum of licensed health care providers with experience in concussion through the terms of medically supervised protocols.10 This is an important area where implementation research has the potential to provide answers based on efficiency and safety. An additional challenge in the initial evaluation of individuals with a suspected concussion in clinical settings is to achieve a more homogenous understanding of concussion diagnosis and management by medical doctors in primary care and emergency department environments. Further educational efforts to establish a consistent understanding of the current best practice for the assessment and management of concussion will facilitate improved clinical care and proper medical management in the event that a concussion does occur. From a research perspective, the heterogeneity of SRC presents additional challenges. For research in health care settings, an ongoing challenge is the diagnosis of concussion with proper consideration for the presence or absence of associated conditions such as cervical injury, post-traumatic headaches, or vestibulo-ocular dysfunction. Further refinement of the definition of concussion in sport and identification of concurrent injuries is imperative to understand the full spectrum and true epidemiologic denominator of all SRCs. Also, in situations of limited timely access to qualified resources, one of the questions that should be addressed is as follows: to what extent can families, sport environments, and schools be safely empowered in the management of suspected concussions that have an obvious and rapidly favorable evolution? Future research should examine whether, in such environments with limited resources, nonphysicians can be safely trained to identify and manage suspected concussion cases that have an obvious and rapidly favorable evolution. In conclusion, although some implementation challenges remain, especially in environments with less resources, the 5th International Consensus Statement in Concussion in Sport introduces important and clinically useful changes based on an increasingly rigorous methodology. These recommendations will prove very useful in the counseling and empowerment of clinicians, patients, families, sport, and school environments in the management of the recovery after SRC. The statement is available at no cost, along with the associated tools at [http://bjsm.bmj.com/content/51/11].

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