Evaluation and management of concussion in sports: Guideline Update

American Academy of Neurology (AAN) has released guidelines of Update: Evaluation and management of concussion in sports in March 2013 and Reaffirmed April 30, 2022.

Following are its major recommendations:

Clinical Context: Preparticipation Counseling

1. School-based professionals should be educated by experienced licensed health care professionals (LHCPs) designated by their organization/ institution to understand the risks of experiencing a concussion so that they may provide accurate information to parents and athletes. (Level B)

2. To foster informed decision making, LHCPs should inform athletes (and where appropriate, the athletes' families) of evidence concerning the concussion risk factors as listed below. Accurate information regarding concussion risks also should be disseminated to school systems and sports authorities. (Level B)

Clinical Context: Use of Checklists and Screening Tools for Suspected Concussion

3. Inexperienced LHCPs should be instructed in the proper administration of standardized validated sideline assessment tools. This instruction should emphasize that these tools are only an adjunct to the evaluation of the athlete with suspected concussion and cannot be used alone to diagnose concussion. These providers should be instructed by experienced individuals (LHCPs) who themselves are licensed, knowledgeable about sports concussion, and practicing within the scope of their training and experience, designated by their organization/institution in the proper administration of the standardized validated sideline assessment tools. (Level B)

4. In individuals with suspected concussion, these tools should be utilized by sideline LHCPs and the results made available to clinical LHCPs who will be evaluating the injured athlete. (Level B)

5. Team personnel (e.g., coaching, athletic training staff, sideline LHCPs) should immediately remove from play any athlete suspected of having sustained a concussion, in order to minimize the risk of further injury. (Level B)

6. Team personnel should not permit the athlete to return to play until the athlete has been assessed by an experienced LHCP with training both in the diagnosis and management of concussion and in the recognition of more-severe TBI. (Level B)

7. LHCPs caring for athletes might utilize individual baseline scores on concussion assessment tools, especially in younger athletes, those with prior concussions, or those with preexisting learning disabilities/ADHD, as doing so fosters better interpretation of postinjury scores. (Level C)

Clinical Context: Neuroimaging for Suspected Concussion

8. CT imaging should not be used to diagnose SRC but might be obtained to rule out more serious TBI such as an intracranial hemorrhage in athletes with a suspected concussion who have loss of consciousness, posttraumatic amnesia, persistently altered mental status (Glasgow Coma Scale <15), focal neurologic deficit, evidence of skull fracture on examination, or signs of clinical deterioration. (Level C)

Clinical Context: Return to Play (RTP)-Risk of Recurrent Concussion

9. In order to diminish the risk of recurrent injury, individuals supervising athletes should prohibit an athlete with concussion from returning to play/practice (contact-risk activity) until an LHCP has judged that the concussion has resolved. (Level B)

10. In order to diminish the risk of recurrent injury, individuals supervising athletes should prohibit an athlete with concussion from returning to play/practice (contact-risk activity) until the athlete is asymptomatic off medication. (Level B)

Clinical Context: RTP-Age Effects

11. Individuals supervising athletes of high school age or younger with diagnosed concussion should manage them more conservatively regarding RTP than they manage older athletes. (Level B)

12. Individuals using concussion assessment tools for the evaluation of athletes of preteen age or younger should ensure that these tools demonstrate appropriate psychometric properties of reliability and validity. (Level B)

Clinical Context: RTP-Concussion Resolution

13. Clinical LHCPs might use supplemental information, such as neurocognitive testing or other tools, to assist in determining concussion resolution. This may include but is not limited to resolution of symptoms as determined by standardized checklists and return to age-matched normative values or an individual's preinjury baseline performance on validated neurocognitive testing. (Level C)

14. LHCPs might develop individualized graded plans for return to physical and cognitive activity, guided by a carefully monitored, clinically based approach to minimize exacerbation of early postconcussive impairments. (Level C)

Clinical Context: Cognitive Restructuring

15. LHCPs might provide cognitive restructuring counseling to all athletes with concussion to shorten the duration of subjective symptoms and diminish the likelihood of development of chronic postconcussion syndrome. (Level C)

Clinical Context: Retirement from Play After Multiple Concussions-Assessment

16. LHCPs might refer professional athletes with a history of multiple concussions and subjective persistent neurobehavioral impairments for neurologic and neuropsychological assessment. (Level C)

17. LCHPs caring for amateur athletes with a history of multiple concussions and subjective persistent neurobehavioral impairments might use formal neurologic/cognitive assessment to help guide retirement-from-play decisions. (Level C)

Clinical Context: Retirement from Play-Counseling

18. LHCPs should counsel athletes with a history of multiple concussions and subjective persistent neurobehavioral impairment about the risk factors for developing permanent or lasting neurobehavioral or cognitive impairments.

19. LHCPs caring for professional contact sport athletes who show objective evidence for chronic/persistent neurologic/cognitive deficits (such as seen on formal neuropsychological testing) should recommend retirement from the contact sport to minimize risk for and severity of chronic neurobehavioral impairments.

Reference:

Christopher C. Giza, Jeffrey S. Kutcher, Stephen Ashwal, Jeffrey Barth, Thomas S.D. Getchius, Gerard A. Gioia, Gary S. Gronseth, Kevin Guskiewicz, Steven Mandel, Geoffrey Manley, Douglas B. McKeag, David J. Thurman, Ross Zafonte Neurology Jun 2013, 80 (24) 2250-2257; DOI: 10.1212/WNL.0b013e31828d57dd