EVIDENCE-BASED ANSWER
Athletes sustaining a concussion should be held from contact activities a minimum of 7 days; they must be asymptomatic and their coordination and neuropsychological tests should have returned to their pre-injury baseline (strength of recommendation [SOR]: B, based on multiple prospective cohort studies). High-risk athletes (eg, those with a history of previous concussion, high-school age or younger, or female) may need to avoid contact even after all these criteria are met (SOR: C, expert opinion).
CLINICAL COMMENTARY
Management of an athlete after concussion should be handled on an individualized basis
Sourav Poddar, MD
Team Physician, University of Colorado Buffaloes; Department of Family Medicine, University of Colorado Health, Sciences Center
Immediate sideline testing should include symptom and cognitive screening as well as a thorough neurologic exam. Any deficits should warrant withholding the athlete from returning to the game. Given the myriad of guidelines published, the importance of following an athlete to complete symptom resolution in the subsequent postconcussive period cannot be overstated. If resources—such as baseline neuropsychologic, postural stability, and other data—are available, these tests can be used to help make the decision to return a symptom-free athlete to full-contact activity. When these additional assessments are back to baseline, they provide valuable objective markers in postconcussive recovery. In the absence of any baseline neurocognitive and other ancillary data, the athlete should be held from contact activity for at least a week after symptoms resolve. These recommendations should be modified for those having sustained multiple or higher-grade concussions.
Evidence summary
Concussion, as defined by the American Association of Neurologists, is “a trauma-induced alteration in mental status that may or may not involve loss of consciousness.”1 There are approximately 300,000 sports-related concussions sustained each season in the US, although many athletes do not recognize the symptoms of concussion or may under-report them.
While concussions usually result in no long-term sequela, persistent neurocognitive deficits and psychiatric illnesses, including depression, may result. Case reports exist of fatal brain swelling in athletes who suffer a second head injury while still recovering from a first one, although more recently the existence of a “second impact syndrome” has been disputed.2
A large prospective cohort study of 2900 US college football players found that players with 1 previous concussion had a 40% increased risk of future concussion, and those with 3 previous concussions had a three-fold increase in risk.3 High school students with concussions are 3 to 4 days slower in recovering memory function than college students,4-6 and women with concussions are 1.7 times more likely to have cognitive impairment than men.7
Concussions are often accompanied by symptoms and cognitive problems that can be overlooked if not carefully and systematically assessed. A prospective study of high-school athletes demonstrated that neuropsychological dysfunction takes a week or longer to resolve in “ding” concussions (defined as no loss of consciousness and overt symptoms resolved within 15 minutes).8 A prospective cohort study of boxers at the US Military Academy found that it takes 3 to 7 days for recovery of neurocognitive function.9 Another cohort study of US college football players found that while postural stability commonly returns in just a day or 2, cognitive recovery often takes 3 to 5 days, and symptoms last over 7 days post-injury for 1 of 8 concussed athletes.10
Sport concussion assessments should include testing for cognition, postural stability, and self-reported symptoms. Results can then be compared with each individual’s preseason baseline. Examples of screening instruments include SCAT (the Sideline Concussion Assessment Tool),11 SAC (the Standardized Assessment of Concussion), BESS (the Balance Error Scoring System), as well as ImPACT or other neurocognitive tests, to evaluate and document memory, brain processing speed, reaction time, and postconcussive symptoms.10-12 SCAT, SAC, and BESS can be used on the sidelines, and each can be employed for baseline and follow up testing.