The New Playbook on Concussions: Updated Guidelines for Prevention, Management, and Recovery

An estimated 1.6 to 3.8 million sports-related concussions occur annually in the United States, a number that has steadily risen over the past two decades.^1,2

This growing prevalence has driven continued advancements in concussion management, propelled by heightened awareness, mounting research, and increased media focus. Reflecting on the latest developments, the 6th International Conference on Concussion in Sport (Amsterdam 2022) unveiled an updated consensus statement, offering new insights and recommendations on the definition, prevention, screening, management, and recovery of sports-related concussions.³ These updates aim to enhance safety, streamline care, and improve outcomes for athletes at all levels. This article will review those recommendations and explore their relevance in the context of emergency medicine care.

Updated Concussion Definition

The Concussion in Sport Group (CSG) redefined sports-related concussions as traumatic brain injuries caused by a direct blow to the head, neck, or body during sports activities, with forces transmitted to the brain. The injury is theorized to result in a cascade of neurological and metabolic changes that may cause a range of symptoms such as headaches, dizziness, or balance disturbances which may emerge immediately or evolve over hours and days. Concussions do not show abnormalities on routine imaging like MRI or CT scans. The CSG continues to work towards a unified and operational definition as the breadth of research on the topic and understanding of head injuries continues to grow. There is currently no universally accepted or standardized diagnostic criteria for concussion.

Prevention

The consensus guidelines emphasize preventative strategies and their importance in reducing concussion incidence and recurrence. Awareness of these strategies can help emergency medicine clinicians educate patient athletes, parents, and coaches and hopefully decrease the risk of concussions for athletes. Specific examples include:

• Rule Changes: Reducing collisions and high-risk actions has been associated with a decrease in concussion incidence. A meta-analysis and systematic review found that disallowing body checking in youth hockey was associated with a 58% reduction in concussion rates. Limiting the amount of full-contact practice in American football was associated with a 64% reduction in concussion rates.⁴
• Protective Equipment: Mouthguards are recommended for all levels of contact play. Use of mouthguards among hockey players of all ages showed a 28% reduction in concussion rates.⁴ Helmets and headgear are likely protective as well; however, more research is needed to support recommendations on these.
• Neuromuscular Training (NMT): Warm-up programs focusing on neuromuscular control demonstrated lowered concussion rates as well fewer musculoskeletal injuries. Rugby players who underwent the NMT training protocols three times per week had 59% fewer concussions compared to the control group.⁵ NMT training included at least 20 minutes of integrated balance, resistance, and plyometric training with sport-specific maneuvers and verbal feedback and reinforcement from coaches. Further research is still needed across other sports and populations.
• Optimal Management Strategies and Education: Recommended strategies— including mandatory removal from play following concussions, concussion clearance protocols, and awareness campaigns focused on education of coaches, parents, and athletes—together have been associated with a 63% reduction in rates of recurrent concussions.⁴

While emergency medicine physicians may be more focused on the treatment and management of concussions after the initial injury, providing education and reinforcing these strategies can help prevent future concussions for athletes in the community.

Screening Tools

Revised concussion screening tools include the Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6^th Edition (SCAT6), and Child SCAT6 for field assessments as well as the Sport Concussion Office Assessment Tool (SCOAT6) for following clinical settings. These tools are most effective within 72 hours of injury and support serial evaluations throughout recovery. For example, the SCAT6 involves several steps that evaluate the athlete’s background, symptoms, cognitive function (orientation, memory, and concentration), coordination and balance, and delayed recall.⁶ This provides a framework for the athlete to receive standardized evaluations, which can be used to track the severity of their concussion and monitor improvement over time. Familiarity with these screening tools can aid physicians in diagnosing concussions in the ED and can help guide patient education and safe disposition planning.

Management

Updated recommendations emphasize early physical and cognitive activity with targeted treatments, with core concepts detailed below. Newer research has continued to support that strict rest is not as beneficial as early return to physical and cognitive activity at light intensity as tolerated,⁷ which is a continued shift from concussion management in the past.

• Immediate Removal: Any athlete with a suspected possible concussion should be removed from play immediately. Initial signs may include loss of consciousness, confusion, amnesia, behavioral changes, seizure, impaired balance, or ataxia.
• Early Physical Activity: Relative but not strict rest is recommended after sustaining a concussion. Athletes should be encouraged to do their normal activities of daily living as tolerated within the 24 hours after the injury. Light aerobic exercise within 24-48 hours has been shown to improve recovery from concussion.⁷ Examples include walking, stationary cycling, and other physical activities if they avoid physical contact, collisions, or falls. Activities should be symptom-limited, with intensity adjusted based on tolerance.
• Gradual Increase in Exertion. Anaerobic exercise, physical activity, and cognitive exertion should be gradually increased over time, and stopped if concussion symptoms are exacerbated. Recovery and return protocols are reviewed below.
• Reduce Screen Use: Athletes should reduce screen time on electronic devices during the first 48 hours after sustaining a concussion. Increased screen use during the initial recovery period has been associated with both an increased duration of recovery and increased symptom severity scoring.^8,9 Reduced screen use beyond 48 hours may not be effective but should be limited by symptom exacerbation.
• Targeted Rehabilitation: Cervicovestibular rehabilitation therapy is recommended and beneficial for athletes with persistent symptoms like headaches or dizziness that last for more than 10 days after the initial injury.¹⁰ Referral to specialists is advised for complex cases involving migraines, cognitive challenges, or psychological issues lasting more than two weeks.

Recovery and Return Protocols

Return to Learn (RTL): Most athletes resume academic activities within 10 days.¹¹ Many student athletes may return to school with minimal difficulty or limitations, while others may require a targeted stepwise symptom-limited return strategy. Initial adjustments should be communicated to the patient’s educators, which may include limited screen use, reduced workload, curriculum and testing adjustments, modified school attendance, and frequent breaks from cognitive tasks. Strict rest or avoidance during the initial 24-48 hours should not be recommended. Duration of tasks may begin at 5 to 15 minutes at a time with incremental increases in cognitive load over time, ensuring no significant or prolonged symptom exacerbation. Mild symptom exacerbation is typically brief and has not been associated with delayed recovery.

Return to Sport (RTS): There is strong and clear evidence to suggest that strict rest is not beneficial in the immediate recovery phase after sustaining a concussion.^7,12 The proposed recovery strategy involves a stepwise approach detailed below. Each step generally takes a minimum of 24 hours, and if more than mild symptom exacerbation occurs, the athlete should stop and attempt to exercise the following day. All athletes should be evaluated by a medical provider and determined to be safe to return to sport prior to engaging in activities at risk of head impact including physical contact, collisions, or falls.

• Step 1: Symptom-limited activities may be started within the first 24 hours of injury. This generally includes daily activities of living and walking. Activities during any stage should not cause more than a mild or brief exacerbation of symptoms, defined as no more than a 2 on a 0 to 10 point scale (0=no symptoms, 10=worst symptoms imaginable).
• Step 2A/2B: Gradual progression generally starts with aerobic activity. Athletes should progress to light activity up to approximately 55% of their max heart rate (step 2A), then to moderate activity up to 70% of their max heart rate if tolerated (step 2B). Activities in this step may include stationary cycling, walking at a moderate pace, and light resistance training.
• Step 3: If tolerating aerobic activity, athletes then progress to individual sport-specific exercises such as running, change of direction, and individual skill drills. There should be no risk of head impact during this step. In general, athletes should be evaluated and cleared by a health care provider prior to progressing to step 4.
• Step 4: Athletes may be integrated into a team environment at this stage and may participate in non-contact training drills and exercises at high intensity. Exacerbation of concussion symptoms during activities in steps 4-6 warrants return to step 3 until there is full resolution of symptoms.
• Step 5: Athletes participate in full contact practice and resume normal training activities. Functional skills and appropriateness to advance should be assessed by coaching staff.
• Step 6: Return to normal game play. Athletes can expect at least 1 week to complete the full RTS rehabilitation strategy and may take longer depending on individual characteristics and tolerance of activity at each step.

Long-Term Considerations

Research into the long-term effects of concussions including depression, neurodegeneration, and traumatic encephalopathy syndrome (TES) remains ongoing but is currently limited. There are increasing concerns that concussions and repetitive head trauma may cause long term cognitive impairment or adverse neurologic outcomes, however current data is limited and is insufficient to suggest or confirm a causal relationship. TES is a clinical diagnosis involving exposure to repetitive head impacts with clinical features of cognitive impairment which follows a progressive course and is not explained by alternative conditions.¹³ Chronic traumatic encephalopathy (CTE) is not a clinical diagnosis but rather is made via post-mortem neuropathology and should not be diagnosed by ED clinicians. Future studies may shed light and help identify the long-term impacts of concussions and repetitive head trauma in athletes.

Conclusion

The consensus guidelines from the 6th International Conference on Concussion in Sport provided new insights and helpful guidance in the management of concussions. Clinicians, coaches, and athletes can collaboratively promote safer sports environments and optimize recovery from concussions by adopting these updated strategies and integrating them into their conversations with patients. Emergency medicine clinicians play a key role in the diagnosis of concussions among athletes and other patient populations and can help to improve the time to recovery, reduce severity of symptoms, and prevent future concussions for these patients.

Take-Home Points

• Concussion is a clinical diagnosis and there are no standardized diagnostic criteria. Head imaging is not indicated unless concern for alternative diagnoses.
• Consider reviewing screening tools such as SCAT6 or CRT6.
• Recommend avoiding unnecessary collisions when possible.
• Recommend mouthguards for all athletes.
• Recommend targeted neuromuscular training in warm-ups.
• Immediately remove any athlete with a suspected concussion from play.
• Early return to physical and cognitive activity should be advised, which should be increased gradually and limited by symptom exacerbation. Do not recommend strict rest.
• Reduce screen use in the first 48 hours.
• Stepwise protocols should be advised for returning to play and to school.
• Athletes should not return to full contact until cleared by a medical provider.
• Consider referral to a concussion specialist if symptoms persist more than 2 weeks.

References

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