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Latest concussion recommendations for adolescents in sports inspire debate
Authors of the statement say that some athletes have returned to play too soon after injury.
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A recent concussion recommendation regarding the care of young athletes is fostering discussion 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 in 2001 and 2004 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 Orthopaedics Today Europe. “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?
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Some have voiced concerns that the recommendation is too broad and takes away the autonomy of the health care professionals.
“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,” American College of Sports Medicine Past President Robert E. Sallis, MD, 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.”
Consensus statement
Those involved in the creation of the statement emphasized that it is a consensus statement and not necessarily a standard-of-care guideline.
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“The consensus statement on concussion in sport is a result of an international conference of experts following the National Institutes of Health guidelines for consensus,” Jiri Dvorak, MD, chief medical officer of the Fédération Internationale de Football Association, told Orthopaedics Today Europe. “The recommendations are directed to all physicians dealing with athletes at all level of play, particularly in the different team sports. In this respect, the consensus statement is an important educational tool not only for the specialized sports physicians on the field, but also for general practitioners who are taking care of athletes at the community level.”
He added, “A specialized physician in neurology, who is seldom present at the sideline, would have much more background to assess an athlete with a potential suspected concussion. On the other hand, to be on the safe side, when there is evidence of concussion, initial rest and no immediate return to play is recommended. This approach has been unanimously supported by the experts.”
Best-practice tips
Lars Engebretsen, MD, PhD, an orthopaedic sports medicine specialist from Oslo, said the consensus statement is based on available research and represents the current best-practice recommendations.
“Clearly more research is needed in this field, in particular on the long-term results of concussions. That said, I think the consensus statement is an excellent educational tool for sports medicine physicians,” he told Orthopaedics Today Europe.
“All sideline physicians should read the paper. They may not agree with everything, and they must certainly use their existing knowledge together with the consensus paper. They should, however, be aware of the fact that the paper was written by the world authorities in this field and therefore use this as part of their sports medicine toolbox,” he said.
Individualized decisions
Per Renström MD, PhD, professor emeritus at Karolinska Institutet in Stockholm and a member of the Orthopaedics Today Europe Editorial Board, said sports medicine specialists continue to be concerned about young athletes returning to competition too soon while they are symptomatic, as well as working with young athletes who have had multiple concussions.
However, “The final decision must be made by the physician who has examined the athlete,” Renström told Orthopaedics Today Europe. “These decisions should be individualized. The consensus statement can be of some support in this decision, which sometimes can be very difficult, considering the pressure from the coach and sometimes the athlete himself. Increasing experience shows that it is better to recommend physical and cognitive rest before activity if there is any uncertainty.”
He acknowledged that it is “an ongoing, continuous process to improve management of this potentially serious problem.” As such, the authors of the consensus statement are planning to formally review and update the consensus statement prior to Dec. 1, 2012, Renström said.
For more information:
- Robert C. Cantu, MD, can be reached at Emerson Hospital, 131 ORNAC Suite 820, John Cuming Building, Concord, MA 01742, U.S.A.; e-mail: rcantu@emersonhosp.org.
- Jiri Dvorak, MD, can be reached at the Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland; e-mail: Jiri.Dvorak@kws.ch.
- Lars Engebretsen, MD, PhD, can be reached at Oslo Orthopaedic University Clinic, Ullevaal University Hospital, University of Oslo, 0407 Oslo, Norway; e-mail: lars.engebretsen@medisin.uio.no.
- Per Renström MD, PhD, can be reached at the Section of Sports Medicine, Orthopaedic Clinic, Karolinska Institutet, SE-171, 76 Stockholm, Sweden; e-mail: per.renstrom@telia.com.
- Robert E. Sallis, MD, can be reached at the Kaiser Permanente Medical Center, 9961 Sierra Ave., Fontana, CA 91730, U.S.A.; e-mail: Robert.E.Sallis@kp.org.
Reference:
- McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport — The 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Brit J Sport Med. 2009;43(Suppl_1):i76-i84.