American Academy of Neurology Recommendations for Sports Concussions

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The American Academy of Neurology conducted an evidence-based study of sports-related concussions that was published in 2013. The recommendations that AAN made are premised on the understanding that players who experience a concussion are at risk of developing a more serious brain injury if they sustain a second concussion before the first injury heals. These are the key recommendations that are designed to protect players from a second, potentially devastating brain injury.

Before Competition Begins

  1. Athletic directors and coaches should receive education and counseling about the risks, evaluation, and management of concussions. That counseling should be provided by a licensed health care provider who is familiar with current standards and practices governing sports-related brain injuries.
  2. School officials in charge of athletic programs and individual sports should, in turn, educate staff members, parents, and student-athletes about the risks associated with brain injuries and the need to manage concussions conservatively.

Sideline Screening

  1. Any player who is suspected of having sustained a concussion should be removed from play immediately to avoid the risk of further injury.
  2. The player should then be screened on the sideline. Sideline screening should be conducted by a health care professional who has been trained in proper screening techniques.
  3. The person who screens the athlete should use standardized assessment tools but should not rely on those tools exclusively. The study identified three reliable concussion assessment tools. The Post-Concussion Symptom Scale (PCSS) and the Graded Symptom Checklist (GSC) are, as their names suggest, simple checklists of symptoms associated with concussions. The Standardized Assessment of Concussions (SAC) is a six-minute test of orientation, concentration, immediate memory, and delayed recall.
  4. If, upon completion of the assessment, the suspicion remains that the player sustained a concussion, the player should not be returned to play. Rather, the player should receive a clinical evaluation by a licensed health care provider. Results of the assessment tools and other observations of the player should be communicated to the health care professional who makes the clinical diagnosis.

Diagnostic Procedures

  1. Players referred for a clinical diagnosis should undergo neuropsychological testing administered by a properly trained health care professional. Test results should be evaluated by a neurologist. The study identified helpful tests that assess memory performance, reaction time, and the speed at which the brain processes information. Other tests assess the athlete’s ability to maintain balance and stable posture.
  2. In appropriate cases, particularly those involving a loss of consciousness, a skull fracture, or persistent symptoms of memory loss or disorientation, a CT scan may be needed to rule out dangerous conditions that may accompany a traumatic brain injury, including internal bleeding or swelling.

Management of a Diagnosed Concussion

  1. If a clinical evaluation results in a diagnosis of concussion, the player should not be allowed to play the sport again until a health care professional is satisfied that the injury has healed. Playing the sport includes practicing the sport if the practice involves risk of violent contact with another player or any other risk of a further head injury.
  2. If medication has been prescribed for treatment of the concussion, the player should not be allowed to play or practice the sport until the player has completed the course of medication.
  3. Players who are in high school or earlier grades should be managed more conservatively than college or adult players. Evidence suggests that brain injuries in younger players take longer to heal. The prolonged healing period should be taken into account when deciding whether a player is ready to return to play.
  4. The passage of time is only one factor that determines whether healing is complete. The health care professional who clears a player to return to play should use valid assessment instruments as well as other available information to make an informed judgment as to whether the injury has healed.
  5. In some cases, it may be necessary to create a plan to allow the player to return to play on a graduated basis. For instance, a player might initially return to practice with a "redshirt" status that protects the player from physical contact with other players. The player should be monitored to determine the player’s response to increased levels of activity.
  6. Athletes who experienced brain injuries may benefit from cognitive restructuring. In simple terms, cognitive restructuring is a form of brief psychological counseling that may include education about the nature of the injury, reassurance about the likelihood of recovery, and assistance in helping players understand that new symptoms they experience are probably not caused by a worsening brain injury. Cognitive restructuring helps players "bounce back" and recover their confidence. Some studies suggest that cognitive restructuring reduces the likelihood of post-concussion syndrome.
  7. In some cases, athletes should retire from play. That determination is most commonly made after an athlete experiences multiple concussions, is diagnosed with post-concussion syndrome, or shows other symptoms of a persistent brain injury. In those cases, the risk of a permanent or disabling injury outweighs the benefits of continuing to play the sport. Health care professionals should recognize those cases and should counsel athletes accordingly.

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