New guidelines rule out same-day return to play for athletes with concussion

The fourth consensus report from the Concussion in Sport Group (CISG 4) represents the latest recommendations from an expert panel, sponsored by five international sports governing bodies. "The statement now makes clear that no athlete at any age or level of competition should be returned to play on the same day a concussion is diagnosed," write Drs. Allen K. Sills, Gary Solomon, and Richard Ellenbogen. Drs. Sills and Ellenbogen were among the experts representing neurosurgery at last year's meeting of the CISG.

Update on Sports Concussion Includes New Assessment Tools

The CISG has met every four years since 2000, with the goal of establishing updated "worldwide policy guidelines for the diagnosis, management, and treatment of sports-related concussion." In a special correspondence, Dr. Sills and coauthors summarize the CISG 4 recommendations for their neurosurgical colleagues.

"Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously," Dr. Sills and coauthors write. According to the consensus statement, 80 to 90 percent of concussions resolve within seven to ten days. In children and adolescents, recovery may take longer. The CISG 4 acknowledges that some patients may develop more prolonged symptoms after concussion.

The updated statement emphasizes the distinction between concussion and mild traumatic brain injury. The CISG 4 suggests that patients with concussion have normal findings on brain neuroimaging studies (such as CT scan), while those with traumatic brain injury have abnormal imaging findings.

To encourage prompt and appropriate recognition, the CISG 4 introduces a new "Concussion Recognition Tool" (CRT) to help coaches, parents, and other nonmedical personnel to identify patients who need immediate medical attention. A printable PDF of the Pocket CRT can be downloaded at: http://links.lww.com/JSM/A32.

The CISG 4 also includes an updated version of the "Sport Concussion Assessment Tool 3" (SCAT 3) for use by medical professionals. A new version of the Child SCAT 3 for use in children aged 5 to 12 was developed as well, reflecting differences in assessment of suspected concussion in children.

No Same-Day Return to Play after Suspected Concussion

In the "most strongly worded change" from past versions, the CISG 4 rules out any possibility of same-day return to play for athletes with suspected concussion -- at any age or any level of competition. Cognitive assessment is recommended as part of overall concussion management. Formal neuropsychological tests may be helpful, but are not required.

The statement calls for physical and cognitive rest until symptoms of concussion resolve. After that, athletes can follow a "graduated program of exertion" until they receive medical clearance to play.

Otherwise, decisions about concussion management and return to play should be individualized, based on the treating doctor's clinical judgment. While medical evidence for rest after concussions remains sparse, the CISG 4 recommends an initial 24- to 48-hour rest period, followed by a "sensible and gradual return to usual activities."

The authors acknowledge the need for further evidence in several key areas -- including issues related to specific tests and assessment methods and long-term outcomes. Dr. Sills and coauthors conclude, "Despite their limitations, the CISG 4 recommendations remain the most widely accepted and quoted standards for sports concussions."