What’s New in Concussion Care – An Update to Concussion Management Guidelines

 

Every 4 years since 2001, the Concussion in Sport Group, a group of researchers, clinicians and experts in the concussion world, gathers to review the most recent evidence and create what is called a consensus statement for concussion management. This statement, usually known as the consensus guidelines, forms the basis and framework for evidence-based concussion management. In this article we will review the most recent concussion consensus guideline, published following the 2022 Concussion in Sport Group Consensus Conference in Amsterdam, focusing on what is new this year versus in the last guideline from 2017.

 

What is a consensus guideline?

 

Basically, after reviewing all of the pertinent evidence, a group of experts is appointed by the organising committee to review the evidence and make recommendations on its implementation. If you’re interested in learning more about the consensus process, you can check out this figure.

 

In short, after this complex process, a paper is written, reviewed and eventually published, giving us the guidelines that we can implement into our clinical practice day to day. Why is this so valuable? When we use expert consensus guidelines to guide our clinical practice, we know that our clients are getting the absolute best possible care, according to established evidence. That means concussion management that is both SAFE and EFFECTIVE, translating into better outcomes, quicker and more complete recovery.

 

The “R”s of Sport-related concussion

 

Recognise: definition of sport-related concussion 

 

The guidelines published in 2016, widely known as the Berlin guidelines described concussion as:

“SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.”

 

The Amsterdam guidelines published in 2023 (the ones we’re reviewing today!) state the following:

 

“Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain. Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged.

 

No abnormality is seen on standard structural neuroimaging studies (computed tomography or magnetic resonance imaging T1- and T2-weighted images), but in the research setting, abnormalities may be present on functional, blood flow or metabolic imaging studies. Sport-related concussion results in a range of clinical symptoms and signs that may or may not involve loss of consciousness. The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction) or other comorbidities (such as psychological factors or coexisting medical conditions).”

What is new in the updated concussion guidelines? Mentioning the fact that while no abnormalities are seen in standard neuro-imaging (CT, MRI), more advanced imaging techniques may show changes in the brain. This is HUGE! This consensus statement acknowledges what we have all suspected for years: that a concussion does injure the brain and does cause actual injury to the brain tissues. Most people with concussion who [resent to their local doctor’s office or ER may have a CT scan done, which will show only more serious damage to the brain. Thanks to the more sophisticated tools available to us in the research world, we can now SEE that concussions do cause changes in the brain! What does this mean for the future? We may be able to eventually diagnose concussion using objective imaging and monitor healing as well.

Reduce: prevention of concussion

Prevention should be at the forefront of any team or organisation’s concussion management plan. Here are the latest recommendation regarding prevention of concussion, again based on the latest research available:

• “Mouthguard use should be supported in child and adolescent ice hockey.”¹

Over the last few years, there has been more and more evidence supporting certain initiatives to reduce concussion incidence. One of those things is mouthguard use. This year’s guidelines firmly support mouthguard use as research showed a massive 28% decrease in concussions among the youth involved in this study! While we can’t be sure that mouthguard use reduces concussion in other sports, I think we can safely say that mouthguard use should be encouraged in all contact sports.

• “Policy disallowing body checking should be supported for all children and most levels of adolescent ice hockey.
• Strategies limiting contact practice in American football should inform related policies and recommendations for all levels.”¹

Again, over the last few years there have been several studies showing that increased incidence of head impact is associated with higher incidence of concussion, and that head impacts in practice and game play should be limited in hockey and American football. This is a common sense recommendation that if we limit the opportunities for head impact, we will also limit the opportunity to sustain concussion. Less impacts = less concussions! 

• “NMT [neuromuscular training] warm-up programmes are recommended, based on research in rugby, and more research is needed for female athletes and in other team sports specifically targeting exercise components aimed to reduce concussion rates.”¹

What is neuromuscular training? It is a collection of exercises targeting strength, balance and agility that can be done as part of a team’s pre-game warm-up. Think single leg hops, carioca, shuttle runs, Nordic curls, planking, and sport-specific skills that fire up the brain and muscles to get an athlete ready for play.

This point is important because we finally have a recommendation of something that athletes themselves can do to prevent concussion, allowing them to take control! Many of our prevention recommendations in the past were at the macro level, targeting rule changes, or overall training volume. Now we finally have something that targets the athlete themselves! 

Looking for more information about NMT training or examples of appropriate warm-up plans for different sports? Check out this website from the University of Calgary for sport-specific warm-up plans.

REMOVE: sideline evaluation

Important changes have been suggested in the on and off-field assessment of athletes who have sustained concussions. First, removal from play of ANY athlete who exhibits possible signs of concussion:

“Signs that warrant immediate removal from the field include actual or suspected loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioural changes and amnesia.21 Players exhibiting these signs should not return to a match or training that day, unless evaluated acutely by an experienced HCP with a multimodal assessment (as noted below) who determines that the sign was not related to a concussion (eg, the player has sustained a musculoskeletal injury and thus unable to balance).”¹

Recognition and removal from play is paramount! Athletes with possible concussion must be removed from play immediately and assessed by a knowledgeable health care provider.

In order to assess the athlete properly, we have an update to the SCAT5 tool, we now have the SCAT6! This tool is now recognized to be optimal for use up to 72 hours after concussion, but can be used up to 7 days. You can find the tool here. What changes will you find in the SCAT6? Longer word and number lists, more complex balance tasks. Basically, a more complex and multi-modal assessment.

What can we use if the athlete presents to us more than 7 days after concussion? The Amsterdam conference also created the SCOAT6 (adult and a child version) for use beyond 7 days post-injury. You can find that tool here. If you’re working with people with concussion, this tool will help you perform a complete assessment of your clients, including dual-taking and cognitive screening.

Re-Evaluate

 

As mentioned above, the SCAT6 is appropriate for on-field assessment of concussion, as well as assessment up to 72 hours post-injury. One of the most useful tools, in my opinion, that the Amsterdam conference has given us is the SCOAT6, a dedicated, comprehensive concussion assessment tool for use in an OFFICE setting. This tool is appropriate for assessment concussions that have happened at least 7 days ago. In addition to a subjective report and concussion history elements, it encompasses assessments of balance, cognition, dual-tasking, cervical spine mobility and  a short vestibular and oculomotor screen. Basically, all of the elements that you would need to assess in a first visit.

 

The SCOAT6 will be a very useful tool in helping to identify what systems need further assessment, and which can be targeted for treatment. If a client scores low on the cognitive screen, a referral to neuropsychology may be warranted. Difficulties with the balance and vestibular screening? Treatment with a knowledgeable vestibular physiotherapist could be indicated. Headache, limited neck mobility and cervical muscle tension? A full biomechanical neck assessment may be warranted.

 

If you’re a therapist treating patients with concussion off the field, know the SCOAT6! You can find it here.

Rest and Exercise

 

20 years ago, when the first concussion care guidelines were published, it was recommended to rest until symptoms resolved. That recommendation didn’t make sense then, and it doesn’t make sense now, however for some reason, the myth that ‘rest is best’ has persisted. Over the years, we have seen with each successive publication, the amount of rest that is recommended after concussion has been reduced, and the recommendation for early activity has increased. I am THRILLED to report that with this latest guideline, the recommendations for appropriate amounts of rest and early return to physical activity are CLEAR. Here they are:

 

“The best available evidence shows that recommending strict rest until the complete resolution of concussion-related symptoms is not beneficial following SRC. Relative (not strict) rest, which includes activities of daily living and reduced screen time, is indicated immediately and for up to the first 2 days after injury.30 

 

Individuals can return to light-intensity physical activity (PA), such as walking that does not more than mildly exacerbate symptoms, during the initial 24–48 hours following a concussion.30”1 

 

In case that wasn’t clear enough:

 

“Clinicians are encouraged to recommend early (after 24–48 hours) return to PA as tolerated (eg, walking or stationary cycling while avoiding the risk of contact, collision or fall).30

The best data on cognitive exertion show that reduced screen use in the first 48 hours after injury is warranted but may not be effective beyond that.31 32”1

 

Again, in case that wasn’t clear enough, here are those recommendations summarised in plain language:

 

• STRICT REST IS NOT BENEFICIAL FOLLOWING CONCUSSION!
• Relative rest, i.e. taking it easy, doing household tasks and reducing screen time for up to 48 hours IS BENEFICIAL
• Rest beyond 48 hours IS NOT BENEFICIAL
• Health care providers should be recommending early return to light physical activity as tolerated (symptom exacerbation <2/10) 48 hours after concussion

 

While we won’t be taking a deep dive into the literature that supports these recommendations, trust me and the consensus group when we say that it is there and these are recommendations based on literally YEARS of scientific research. 

 

My clinical experience also bears this out. Clients that I have worked with who have adhered to strict rest after concussion tend to have very difficult rehab journeys, and have a difficult time starting to be active again. The clients that I work with who have either been encouraged to be active early or who ignored advice to rest, are those who have had the best outcomes after injury.

 

I’ll never forget the case of a young man with a relatively straightforward concussion who was instructed by his family doctor to stop all school activities, physical activity and social activities and to rest until he felt better. He came to see me after 8 weeks of rest! His rehab dragged on for months, and getting back into life after having rested that long was a real challenge. I am on a mission to make sure that no other person gets those same recommendations!

 

Refer

“Where the clinical environment allows, referral to clinicians with specialised knowledge and skills in concussion management should be considered for the targeted treatment of persisting symptoms.37 This may include the management of cervicogenic symptoms, migraine and headache, cognitive and psychological difficulties, balance disturbances, vestibular signs and oculomotor manifestations.”1

 

Concussion is not a simple injury to manage. Referral to professionals with the appropriate skills to assess and treat all of the signs and symptoms that come along with concussion is essential. A team approach is best, as it is impossible that one person can manage all of these symptoms. Our multidisciplinary team at PhysioAvantex Ville Mont-Royal can manage simple and complex concussion cases, and manage all of the symptoms listed above and more. 

 

What is an interesting addition to these guidelines is that we can finally characterise persistent symptoms as symptoms lasting >4 weeks post-injury. We can also now recognize that normal recovery following concussion can last up to 4 weeks post-injury. Previous iterations of the concussion management guidelines stated that usual recovery is 7-10 days, that is now stretched to 4 weeks.

Rehabilitate

“If dizziness, neck pain and/or headaches persist for more than 10 days, cervico-vestibular rehabilitation is recommended. 38 If symptoms persist beyond 4 weeks in children and adolescents, active rehabilitation and collaborative care may be of benefit. For children, adolescents and adults with dizziness/balance problems, either vestibular rehabilitation or cervico-vestibular rehabilitation may be of benefit. The inclusion of subsymptom threshold aerobic exercise (as outlined above) in combination with other treatments should be considered. In the case of a recurrence of symptoms when progressing through the return-to-learn (RTL) or return-to-sport (RTS) strategies, re-evaluation and referral for rehabilitation may be of benefit to facilitate recovery.”1

 

When should rehabilitation be initiated after concussion? 10 days! That means if someone with concussion is still experiencing headache or neck pain after 10 days, they should be referred for rehabilitation immediately.

 

For people with balance or dizziness after concussion, neck treatment and vestibular rehabilitation may help. Subsymptom threshold aerobic exercise may also be included. What does this mean? A multi-modal approach is best for concussion rehab. A team comprising therapists with expertise in cervical rehabilitation, vestibular rehabilitation, and exercise therapy is needed for optimal concussion rehabilitation and recovery! 

 

Recover

 

How to determine recovery from concussion has always been a challenge. Do we focus on symptoms? Functional capacity? Aerobic exercise tolerance? Successful progression through return-to-sport, return-to-learn, and return-to-work protocols? Improvement on in-clinic tests and measures?

 

The new guidelines actually recommend a combination of all of the above:

 

“Thus, we recommend that clinical evaluation and future research include three components in the determination of recovery:

 

Assessment of symptom reports (including concussion-related symptom resolution at rest, with cognitive activities and following physical exertion).

 

Other outcomes relevant to ongoing symptoms or a specific research question (eg, response to physical exertion, post-traumatic headaches, standing balance, dynamic balance, vestibulo-ocular reflex (VOR) function, oculomotor (OM) function, symptom reproduction with VOR and OM testing (eg, VOMS), cognition, dual tasking).

 

Measures of return to activity such as RTL and RTS”1

 

Successful progression in these measures, combined with the team’s expert clinical opinion is what should be used to assess recovery.

 

Regarding using advanced imaging and fluid biomarkers to assess recovery, the guideline recognizes that these are appropriate in a research setting, but are not yet validated or realistic for use in a clinical setting.

Return-To-Learn/Return-To-Sport

 

A discussion of  the current evidence pertaining to return to learn and return to sport strategies could take up an entire book all on their own! For the purposes of this article, we are going to briefly review and discuss the key points brought up in the Amsterdam guidelines.

 

“The systematic review revealed that the vast majority of athletes (93%) of all ages have a full RTL with no additional academic support by 10 days.41 […} To minimise academic and social disruptions during the RTL strategy, HCPs should avoid recommending complete rest and isolation, even for the initial 24–48 hours, and instead recommend a period of relative rest. Early return to activities of daily living should be encouraged provided that symptoms are no more than mildly and briefly increased (ie, an increase of no more than 2 points on a 0–10 point scale for less than an hour). In consultation with educators, and accounting for social determinants of health, some students may be offered academic supports to promote RTL”¹

 

Once again, for the people in the back: “HCPs should avoid recommending complete rest and isolation, even for the initial 24–48 hours, and instead recommend a period of relative rest. Early return to activities of daily living should be encouraged”.  Again, health care providers should NOT be recommending complete rest. NO COCOONING! There is a wealth of evidence supporting these recommendations, there is no excuse for recommending complete rest when we KNOW that it is harmful. 

 

What is also interesting is that the vast majority of athletes are able to return to school as per usual after about 10 days. To those of us working with athletes with concussion, it can feel like no one ever gets back to learn this quickly, but in reality less than 10% of athletes still require academic support after 10 days. Let’s also keep in mind that return-to-learn and return-to-sport don’t always follow the same time line and return to full academic capacity does NOT mean that an athlete is ready for return to sport.

 

For those athletes who need academic supports to return to learn successfully, the guidelines recommend such modifications as modified attendance (gradual return to school), modified tasks, extra time for tests, excused absence from gym and more.

 

Here is the general RTL strategy that the guidelines recommend. How can this be modified to fit your setting?

 

This brings me to our next set of recommendations, and the ones that are often thought of as the most important: return to sport!

 

Surprisingly, there isn’t a whole lot that is different in our return to sport strategy, but there are a few key differences since 2017.

 

First, here is the complete return to sport strategy:

 

As in 2017, it is recommended that athletes make their way through the RTS strategy in a stepwise fashion, without skipping steps. Each step should take at least 24 hours. What is new is the splitting up of step 2 into 2a (55% of max heart rate) and 2b (70% of max HR). This new recommendation clearly quantifies what level of intensity an athlete should be able to tolerate before moving on to step 3 – individual sport-specific exercise.

 

What is new in step 3 is that we recognize that this step should be completed individually, away from the team environment. This is done presumably to further protect the athlete from any risk of impact or collision. What is also new in this step is that medical clearance should occur before initiating step 3 if there is any risk of head impact. So, if your athlete does an individual sport that may involve falls on a hard surface, or head impacts (hockey & skiing come to mind..), the team physician should clear the athlete to begin this step.

 

Once the athlete has cleared step 3, the rest of the RTS progression can be completed. What is important to note here is that this guideline doesn’t consider step 3 successfully cleared unless there is “resolution of any symptoms, abnormalities in cognitive function and any other clinical findings related to the current concussion, including with and after physical exertion.”What does this mean? An athlete should not progress through to step 4 if they are still symptomatic AT ALL, haven’t fully returned to school or work, or are still experiencing any cognitive or other deficits. This means that progressing through steps 4-6 are our absolute LAST steps in the rehab and recovery process.

Reconsider – Potential Long-term side effects

There is increasing concern about the potential long-term side effects of concussion and repeated head injury. The consensus group reviewed articles relating to increased risk of mental health disorders, cognitive impairment and neurological diseases among former athletes. Here are their summarised findings:

 

Mental health

Reviewed articles didn’t show any increase in mental health disorders (depression, suicidality, or psychiatric hospitalisation). While this is far from covering the full scope of possible mental health impacts, it is encouraging that for the outcomes measured, no increase was seen.

 

Cognitive impairment, neurological disorders, neurodegenerative conditions

While mental health impacts were not found to be increased in the sport populations studied, the picture is different when we look at professional athletes and neurodegenerative conditions. Studies of former professional football and soccer athletes did show increased mortality due to dementia and amyotrophic lateral sclerosis (ALS), a rare but devastating degenerative condition. This information leaves us with several questions: Are amateur athletes at the same risk of developing conditions? What is the threshold of exposure to head impact that leads to increased risk of developing dementia or ALS? At what point in an athlete’s career should we become concerned about the volume or severity of concussion or subconcussive impacts? More research on these questions is sorely needed!

 

Chronic Traumatic Encephalopathy- neuropathological change

 “It is reasonable to consider extensive exposure to repetitive head impacts, such as that experienced by some professional athletes, as potentially associated with the development of the specific neuropathology described as CTE-NC.”¹

 

Chronic traumatic encephalopathy has been a hot topic in the sports world and even in the news in the last few years. What the current guidelines state is that the prevalence of CTE in the general population is unknown, but that it is somewhat higher in brain banks of professional athletes. So, it is reasonable to infer that repeated head impacts could indeed lead to CTE, however, more research is needed!

Retire

 

Questions about when to retire inevitably come up when working with athletes with concussion. Is one long recovery enough to recommend retirement from sports? How many concussions are acceptable and safe for an athlete’s long term brain health? After how many concussions or total recovery days should we recommend retirement?

 

Here are the recommendations:

 

“The discussion should provide athletes with the scientific evidence and uncertainties of their condition balanced against the benefits of participation in sport. It should incorporate the athlete’s preferences and risk tolerance as well as psychological readiness to make an informed decision.[…] Given the positive benefits of exercise on health, care must be taken to avoid restricting all PA. All athletes who ultimately retire from contact or collision sports should be encouraged to continue non-contact or low-contact PA and have the health benefits of exercise explained.”¹

 

What does this mean for us, the clinicians who need to answer these questions from our athletes on a day to day basis? First, the decision is not to be taken lightly or rashly, and should come from a discussion among the athlete, the treating TEAM, and in the case of a child, the athlete’s parents. 

 

There is no set number of concussions that is safe, there is no way for us to say that after ‘X’ number of concussions an athlete should retire from play. The decision needs to encompass the full clinical picture, any residual deficits that may be present, as well as the athlete’s risk tolerance. The retirement discussion may look very different from a recreational hockey player to a professional level athlete, or from a boxer to a volleyball player. The risks versus potential benefits need to be weighed, and those are specific to each athlete’s situation.

 

Refine  

 

While the Amsterdam guidelines are long and rather comprehensive, they do not cover all aspects of sport. The consensus group recognized that there are several other topics that should be included in order to give a more comprehensive overview of concussion management. The group recommends including the following topics for further consideration in future guidelines:

 

Parasport

 “Most significantly, (1) individuals may benefit from baseline testing given the variable nature of their disability and the potential for atypical presenting signs/symptoms of concussion, (2) individuals with a history of central nervous system injury (eg, cerebral palsy, stroke) may require an extended period of initial rest, (3) testing for symptoms of concussion through recovery may require modification such as the use of arm ergometry as opposed to a treadmill/stationary bike and (4) RTS protocols must be tailored and include the use of the individual’s personal adaptive equipment and, for applicable participants with visual impairment, partnership with their guide.”¹

 

This is an important departure from what is recommended for able-bodied athletes. Baseline testing in para-athletes can give us a clear picture of the athlete’s pre-injury status, so we can better compare their clinical picture post-injury. Also, interestingly, athletes who are known for prior CNS injury may require more rest. How much more? Again, more research is needed. Also, return to play protocols must be adapted to the reality of the athlete and incorporate their required adaptations, mobility aids or guides. 

 

Other topics

The committee also recommended further research in the areas of paediatrics. They also recommended that to further strengthen the recommendations of the consensus group that there be a stronger focus on the athlete voice, equity, diversity and inclusion, inclusion of different stakeholder voices and modifications of the consensus process were all mentioned. Also, there was a clear point on the efforts made to increase transparency by declaring conflicts of interest before the beginning of the consensus process. This is a very positive step in light of recent controversy surrounding a lead author of past versions of the guideline.

 

Conclusion

 

After all of this, what are the main takeaway points from the 2023 Concussion in Sport Group Consensus Guideline?

• Recognizing and removing from play is paramount, we can’t treat concussions accurately if we aren’t recognizing them

• We now have the SCAT6 for sideline assessments and the SCOAT6 for in-office assessments

• Healing time: normal healing time can be up to a month!

• We should be recommending 24-48 hours of RELATIVE REST and then a gradual return to activity and life

• We should recommend early return to aerobic activity after a 24-48 hour period of relative rest

• Multimodal rehab should be initiated after 10 days in athletes with dizziness, headache and/or neck pain

• Stepwise return-to-learn and return-to-sport protocols exist and should be implemented 

• Decisions regarding retirement should take into account all the variables relating to an athlete’s condition 

 

And as with every other topic in science…

MORE RESEARCH IS NEEDED ON ALL OF THESE TOPICS AND MORE!

 

If you have had a concussion and are looking for a team to help guide you through your recovery, reach out to PhysioAvantex. We have a team of physiotherapists trained in all the facets of concussion rehabilitation who can help guide you through your recovery to help you achieve your goals. We also have a multidisciplinary team that can assist in the management of more complex, chronic or stubborn concussion cases. Call us today at 514-647-4778!

 

1.  Patricios JS, Schneider KJ, Dvorak J, et alConsensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022 British Journal of Sports Medicine 2023;57:695-711.
2.  McCrory P, Meeuwisse W, Dvorak J, et alConsensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 British Journal of Sports Medicine 2017;51:838-847.