Athletes who might have sustained a concussion during a sporting event should be immediately pulled from play and not return until they have been properly evaluated by a trained health care provider – preferably a neurologist, according to a position statement by the American Academy of Neurology.
The academy issued the new set of recommendations in light of the still-unknown long-term effects of concussion on a young person's developing brain, and because of the risk of sometimes-fatal second-impact syndrome, Dr. Jeffrey Kutcher said in an interview.
The recommendations ideally apply to athletes in any age group but may be of greatest benefit to athletes aged 15-24 years. In this age group, sports are now second only to motor vehicle accidents as the leading cause of traumatic brain injury, according to the statement.
“We need a more individualized, hands-on approach to return-to-play decisions, so we can prevent longer symptoms, and more common symptoms,” said Dr. Kutcher, lead author of the paper and director and chief of inpatient neurologic services at the University of Michigan's NeuroSport Program in Ann Arbor. “If you get hit and stay in the game, and get another hit, you'll have more symptoms, longer symptoms, be out of school longer, and have more interruption of your daily life.”
Although football is the sport that springs to mind as potentially the most dangerous, Dr. Kutcher said others hold risk as well, including ice hockey, water polo, field hockey, and diving.
The position paper also calls for a certified athletic trainer to be present at all events that pose a risk for concussion, including practices. The idea that certified trainers and physicians should be more consistently involved in contact sports might be a difficult one for some programs to swallow, Dr. Kutcher admitted – especially small, rural areas that may already be short on money and resources.
However, he said, “if we are going to allow our children to be exposed to this kind of risk, shouldn't we at least require a certified athletic trainer who is able to identify possible concussions [to be] at each practice and game? If not, then maybe we should be readjusting our thinking about having contact sports until the right people are around to protect our children.”
The paper represents an interim update of the academy's 1997 guideline “The Management of Concussion in Sports.” including how repeat concussion plays into second-impact syndrome, cognitive impairment, and even the possibility of a concussion-related dementia, which may develop years after the traumatic brain injury of repeat concussions. Recent long-term studies have found an association between repeat concussions and the onset of “chronic traumatic encephalopathy,” Dr. Kutcher said. “This term has been used to describe pathologic changes seen in the brain at autopsy,” which include tau deposition similar to that of Alzheimer's disease although not in the typical Alzheimer's brain regions. The pathologic changes are visible on microscopy, but we really don't know what these changes might mean clinically,” he said. “That is still under investigation.”
Recently Dr. Kutcher and other members of the practice update committee held conference calls with several national organizations that oversee youth sports, including the American Association of Health Educators.
“We need these groups to partner with the American Academy of Neurology to get this message out – as well as other messages that convey the benefits of fitness [to] brain development and health,” he said. “We hope these are some very positive steps in increasing education about this important issue on a larger scale.”
Dr. Kutcher testified about the issue earlier this year before a congressional Judiciary Committee hearing in Detroit. During that hearing, he made the case for an individualized approach to managing concussion during contact sports.
“Because the brain is a highly complex, individualized, and dynamic organ, concussion management does not lend itself well to the use of protocols. It is, rather, an injury that is best managed by people with neurological expertise and experience treating athletes,” he indicated in his written testimony.
“Unfortunately, the vast majority of athletes who sustain a concussion do not have access to concussion experts. Add to this the fact that approximately half of all high school athletes in this country do not have access to certified athletic trainers or any other medical specialist on site, and the problem deepens. Because of these shortages, sports concussion is a public health issue that could use protocols that can be followed by our country's network of primary care providers, as well as more simple guidelines that can be followed by parents, coaches, friends, and teammates.”