AAN updated Concussion Guidelines

In March of 2013, the American Academy of Neurology released their updated concussion guidelines. This is an update on the 1997 guidelines. One thing that differed in the creation of these guidelines from the 1997 guidelines is that they were created by a panel of mostly nonneurologists (7 of the 12 members). According to Dr. Giza, this is important because the guidelines aren't meant for just neurologists; concussions are seen by other specialists.

The previous guidelines attempted classification of the severity of concussions at occurrence and tried to predict return to play recommendations on that classification. The new guidelines do not have a set time for return to play. That is the major change in the guidelines as evidence has shown that the scales were not indicative of who was taking longer to recover.

The guidelines recommend that a player who has possibly sustained a concussion should be removed from play to minimize risk for further injury and should not return to play until assessment by a licensed health care professional "with training in both the diagnosis and management of concussion and the recognition of more severe traumatic brain injury." Athletes high school age or younger should be managed more conservatively. This is because in studies, it took longer for symptoms and neurocognitive performance to improve.

Other recommendations include:

There is no evidence for pharmacologic interventions.

The risk for concussion is greatest in football and rugby, followed by hockey and soccer. For girls, it's highest is soccer and basketball.

A player with a history of 1 or more concussions is a greater risk for another concussion. The authors found little evidence to support "second impact syndrome" (a second impact in a vulnerable state can lead to cerebral edema and death). A new hypothesis is that residual concussion symptoms put a player at risk for an unanticipated hit due to slow reaction times or cognitive processing.

The first 10 days after a concussion is when there is the greatest risk of being diagnosed with another concussion.

Use of helmets may prevent concussion. Use of unproven protective gear may give a false sense of security putting players at higher risk for concussion as they may be more aggressive.

Health professionals trained in treating concussions should look for ongoing symptoms, concussion history and young age. These have been linked to a longer recovery.

Risk factors linked to chronic neurobehavioral impairment in the professional athelete: prior concussion, longer exposure to the sport, the ApoE4 gene.

Concussion is a clinical diagnosis. Symptom checklists, the Standardized Assessment of Concussion, neuropsychological testing and the Balance Error Scoring system should not be used alone in making a diagnosis.

Although an athlete should be removed from play after a concussion, activities that do not worsen symptoms and do not pose a risk for repeat concussion may be part of treatment.

Health care providers should counsel players with multiple concussions and persistent neurobehavioral impairments for retirement from play decisions.