Am Fam Physician. 2024;110(4):435-436
Author disclosure: No relevant financial relationships.
KEY POINTS FOR PRACTICE
• Relative rest, with reduced screen time and limited activities of daily living, is recommended immediately and for the 2 days following a concussion. Light physical activity is suggested in the first 24 to 48 hours if symptoms are not significantly exacerbated with the activity.
• Progressive return to activity is recommended if symptom exacerbation is only mild and brief, not worsening by more than 2 points on a 10-point scale.
• Referral to a sports-related concussion specialist should be considered for patients who experience severe symptoms or symptoms that persist longer than 4 weeks.
From the AFP Editors
A sports-related concussion is an impact to the head, neck, or body during sport or exercise that results in a temporary loss of normal brain function but does not demonstrate any abnormality on neuroimaging. The Concussion in Sport Group created the 6th International Conference on Concussion in Sport consensus statement to provide updated recommendations on concussion care for athletes at any level of sport.
REDUCING RISK
In several sports, specific policies have reduced concussion risk. In American football, policies decreasing the frequency, duration, and intensity of contact and collisions in practice reduced concussions by 64%. In youth ice hockey, prohibiting bodychecking decreased concussion by 58% and requiring mouthguards reduced concussions by 28%. Participating in an on-field neuromuscular training warm-up program three times a week in rugby is associated with lower concussion rates.
SIDELINE EVALUATION
Players who exhibit loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioral changes, or amnesia should be removed immediately from the field of play. Players with these symptoms may have a concussion or other injury that warrants further assessment.
For evaluation, the Sport Concussion Assessment Tool (SCAT6) can be used for adolescents 13 years or older and adults. Children 8 to 12 years of age can be evaluated using the Child SCAT6. The assessments are more accurate when used within 72 hours of the incident, take at least 10 minutes to complete, and are preferably done in a quiet area. When a concussion is suspected or diagnosed, the athlete should be repeatedly reevaluated because symptoms and signs may evolve with time.
OFFICE ASSESSMENT
When assessing a sports-related concussion in the office, the Sport Concussion Office Assessment Tool (SCOAT6) is recommended for adolescents 13 years or older and adults, or the Child SCOAT6 for children 8 to 12 years of age. These tools can be used to identify specific deficits and to guide individual management. They may be used as the initial assessment or as a comparison to the SCAT6 or Child SCAT6 and be repeated to monitor recovery progress.
The SCOAT6 and Child SCOAT6 tools include history of concussions (including management and recovery time), mental health history, and preexisting headache disorders, because these can be exacerbated by concussion and may require additional evaluation and treatment. Both tools evaluate global symptoms, cognition, vestibulo-ocular disturbances, cervical or neurologic complications, autonomic dysfunction, balance, sleep, anxiety, depression, graded aerobic exercise test results, and possibly computerized cognitive test results. Specific recommended testing includes 10-word immediate recall, backward digit testing (repeating three number sets in reverse order), and orthostatic blood pressure and heart rate testing. Neurocognitive and computer-based tests may be helpful in discerning severe concussion but are not useful in isolation to dictate clinical decisions.
RETURN TO ACTIVITY
To promote recovery following a sports-related concussion, relative rest is recommended for up to 48 hours after the incident. Relative rest includes limited activities of daily living and reduced screen time. Strict rest immediately after the injury or until the resolution of symptoms is not helpful for recovery.
During the initial 24 to 48 hours following a concussion, it is recommended that patients attempt light-intensity physical activity, such as walking, to a level that does not more than mildly exacerbate symptoms. If tolerated, patients can increase their activity intensity as often as every 24 hours based on the symptom exacerbation experienced during previous exercise sessions. If tolerated, athletes may increase aerobic activity based on heart rate, incorporating individual sport-specific training drills, noncontact or contact practice, and then returning to sport. Patients may continue to advance the intensity and duration of physical activity if there are no more than mild and brief exacerbations of their concussion-related symptoms. Mild exacerbations are no more than a 2-point increase in their preexercise severity symptom value on a 10-point scale. Brief exacerbations are those that do not persist longer than 1 hour. Symptom exacerbations that are not mild or brief should lead to at least a 1-day pause in activity. This subsymptom threshold aerobic activity protocol can assist in recovery and reduce the incidence of persistent sports-related concussion symptoms.
School or work accommodations may benefit recovery, including modified attendance, breaks from cognitive tasks, limited screen time, or extra time permitted to complete tasks. Unrestricted return to sport following a sports-related concussion typically occurs within 1 month of the injury, with an average of approximately 20 days.
Some athletes are at higher risk of prolonged symptoms after concussion. Athletes with disabilities are at higher risk of injury and may benefit from baseline testing to improve recognition of atypical presentations. Patients with a history of central nervous system injury may require an extended period of initial rest. Athletes with disabilities may benefit from adjustments during testing and recovery such as use of arm ergometry or other adaptive equipment.
REFERRAL
Persistent or severe symptoms after a sports-related concussion suggest the need for referral for further evaluation or rehabilitation. When dizziness, cervical neck pain, or headaches continue for more than 10 days following the injury, cervicovestibular rehabilitation is suggested. Sleep disturbance lasting more than 10 days is associated with an increased risk of developing prolonged symptoms. Symptoms persisting longer than 4 weeks may require specialists to assist in management. Symptoms may include mental health issues, learning challenges, visual or oculomotor disturbances, vestibular complications, headache disorders, sleep disruption, dysautonomia, and pain.
RETIREMENT
Determining when to retire from or discontinue collision or contact sports is not straightforward. Former amateur male athletes are not at increased risk of cognitive or neurologic disorders compared with men from the general population. Chronic traumatic encephalopathy, associated with professional athletes, is very uncommon in community samples. There are no defined factors to determine the need to discontinue participation in contact sports, and these decisions are complex and multifaceted. Continued low-impact physical activity may be encouraged in patients who discontinue contact sports.
| Score | Criteria |
|---|---|
| Yes | Focus on patient-oriented outcomes |
| Yes | Clear and actionable recommendations |
| Yes | Relevant patient populations and conditions |
| Yes | Based on systematic review |
| No | Evidence graded by quality |
| Yes | Separate evidence review or analyst in guideline team |
| Yes | Chair and majority free of conflicts of interest |
| No | Development group includes most relevant specialties, patients, and payers (no payers or patients) |
| Overall – useful |
Editor’s Note: I appreciate the recommended cognitive and orthostatic testing and especially the return to activity protocol in this guideline. Personally, I’m not as interested in the formal tools they suggest using, because I never have enough time to complete a 15-page document in my own clinic. Some, but not all, of the components of these tools have been validated, and routine use may not be necessary.
—Michael J. Arnold, MD, Assistant Medical Editor
Guideline source: Concussion in Sport Group
Published source: Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med. 2023; 57(11): 695–711.
