Latest concussion recommendations for adolescents in sports cause controversy

Authors of the statement say that some athletes have been returned to play too soon after injury.

Issue: July 2009

A recent concussion recommendation regarding the care of young athletes is causing debate among sports medicine specialists.

In the latest consensus statement on concussion in sport, a panel at the 3rd International Conference on Concussion in Sport in Zurich recommended that children and adolescent athletes who are diagnosed or suspected of having a concussion not return to play the same day that the injury was sustained. Prior consensus statements allowed young athletes to return to play on the same day if cleared by a physician or certified athletic trainer.

“The major concerns are that it is difficult on the sidelines to know whether an athlete is truly cleared from all post-concussion symptoms,” Robert C. Cantu, MD, an author of the consensus statement told Orthopedics Today. “Athletes often falsify that their symptoms have cleared, especially in the heat of sideline assessment. We are also aware there is literature documenting that a number of athletes are being returned to contests too soon while symptomatic.”

Concerns regarding second impact syndrome and problems stemming from multiple concussions have also heightened the importance of proper concussion management, he said.

Setting back the field?

Some have voiced concerns that the recommendation is too broad and takes away the autonomy of the health care professionals.

“I think these new guidelines are really a step backward in the sideline management of concussions,” past president of the American College of Sports Medicine, Robert E. Sallis, MD, said.

“In my opinion, putting out a blanket recommendation saying any player with a certain injury cannot return to play that day is movement in the wrong direction for the field of sports medicine,” he said. “If you are going to recommend against using clinical judgment on the sideline, why have a team doctor or athletic trainer — just get an administrator. If you have an injury, there is no need for evaluation and you just do not go back to play that day. That would be the “safest” approach to take with all injuries.”

No room for deviation

He also argued that the recommendation does little to prevent the risk for a second concussion and noted that the threat to not return to competition may induce athletes and coaches to under-report injuries even more than they do now.

“There is no room for deviation with these new guidelines and I think that it is going to be used by lawyers,” Sallis, who is co-director of the Sports Medicine Fellowship at the Kaiser Permanente Medical Center, said. “I think that current evidence does not support every player with a very minor concussion being blocked from return to play in the same game. This has never been the standard of care before, so why recommend it now?”

Those involved in the creation of the statement highlight that it is not a standard-of-care guideline.

“It is important to keep in mind that the consensus document is just that — a consensus of a group of experts,” panel member and pediatric sports medicine physician, Laura Purcell, MD, said. She also noted that many questions remain regarding concussions, particularly in the young athlete.

“Research is ongoing but, for now, these guidelines represent what we know to date. Because of the concerns regarding children being more vulnerable to concussion, it is prudent to exercise more caution when managing children and adolescents with concussion,” she said.

For more information:

Robert C. Cantu, MD, can be reached at Emerson Hospital, 131 ORNAC Suite 820. John Cuming Building Concord, MA 01742; 978-369-1386; e-mail: rcantu@emersonhosp.org.

Laura Purcell, MD, can be reached at the University of Western Ontario, Department of Pediatrics, 800 Commissioners Road East, Room E6-103, London, Ontario, Canada N6A 5W9; 519- 685-8129; e-mail: lpurcell1015@rogers.com.

Robert E. Sallis, MD, can be reached at the Kaiser Permanente Medical Center, 9961 Sierra Ave., Fontana, CA 91730; 909-477-3903; e-mail: Robert.E.Sallis@kp.org.