Evaluation and return-to-play
The position statement recommends that:
- Athletes at high risk of concussions (those in collision or contact sports) should undergo baseline examinations before the competitive season.
- Baseline examinations be completed annually for adolescent athletes, those with recent concussions and, when feasible, all athletes. (Note: this is a departure from other consensus statements, which do not call for annual baseline exams);
- Baseline exams should consist of clinical history, physical and neurologic evaluations, measure of motor control (balance) and neurocognitive functions. (noticeable by its absence is a recommendation for a baseline King-Devick test, a simple vision test that a growing number of experts believe, and studies show, can help identify athletes with possible concussion on the sports sideline in making the all-important "return/no return decision");
- Any athlete suspected of a concussion should be removed from play; not allowed to return to activity on the day of injury; and received a full follow-up evaluation from a physician or AT;
- Once the concussion diagnosis is made, the patient should undergo daily focused examinations to monitor the course of recovery and be cleared by a physician before returning to play. (Note: written RTP clearance is required under the law of 48 states and the District of Columbia, although some state laws allow the written authorization for return to sports to be made by health care professionals other than a physician);
- Those athletes with a history of concussions or who do not show a typical return to normal functioning after injury (usually in about a week to 10 days, according to most studies) may benefit from a referral to a neuropsychologist (as a brand new study in Pediatrics (Kirkwood MW, et al. 2014) recommends) or additional treatments or therapies. McLeod says one of the "key aspects" of the statement lies in the fact that it "reiterat[es] the importance of the multifactorial assessment and using an interdisciplinary concussion team."
The position statement recommends:
- that ATs enforce the standard use of certified (e.g. NOCSAE) helmets and educate athletes, coaches and parents that, although helmets can help prevent catastrophic injuries, they do not significantly reduce the risk of concussions;
- helmet use in high-velocity sports (e.g. skiing, cycling), which has been shown to protect against traumatic head and facial injury;
- the wearing of mouth guards because, although consistent evidence demonstrating a reduced concussion risk by wearing a mouthguard is not available, the evidence demonstrates that fitted mouthguards do reduce dental injuries;
For younger athletes, the statement recommends:
- that ATs be aware that recovery among young athletes may take longer than in adults and require a longer return-to-play progression;
- use age-appropriate, validated concussion-assessment tools with younger athletes, and that a parent, teacher or responsible adult also monitor and report symptoms;
- young athletes undergo continual brain and cognitive development and may require more frequent updates to their baseline assessments; and
- ATs, school administrators and teachers work together to include appropriate academic accommodations in the concussion management plan.
The position statement calls for:
- implementation of a standard concussion home instruction form for all patients;
- instructing a concussed patient to avoid medications other than acetaminophen, and to avoid alcohol, drugs or other substances during their concussion recovery;
- recommending rest as the best practice for concussion recovery; during the acute stage of injury (the first several days after injury) patients should avoid any physical or mental exertion that exacerbates symptoms, should maintain a healthy diet and stay well hydrated; and
- ensuring that school administrators, counselors and instructors are aware of the patient's injury.
With respect to the management of patients with a concussion history, the statement recommends that:
- the potential for second-impact syndrome be recognized, and an awareness of the potential long-term consequences of multiple injuries; and
- referral to a physician with specific concussion training and experience be considered for athletes with a history of concussions.