Evidence does not support concussion grading
As a family physician who has been teaching and practicing sports medicine for more than 17 years, I found the article on concussion (“Concussion care: Simple strategies, big payoffs,” J Fam Pract. 2009;58:410-414) very disappointing. The reference the evidence is based on is more than 12 years old and advances the use of a concussion grading system that is lacking in any solid medical data. Consensus statements from the 3 international conferences on concussion in sport—held in 2001, 2004, and 2008—state that grading systems should not be used to dictate concussion management. Rather, concussion is seen as an evolving diagnosis that is made when the symptoms stop advancing and a complete return to a neurological baseline is reached. The authors’ statement that patients with a “grade 1” concussion can return to the playing field within 15 minutes as long as their neurologic exam is normal and they have no symptoms is simply incorrect.
The article ignores the newest cognitive testing tools, heralded by the International Concussion Consensus Committee as an evidence-based means of facilitating an athlete’s safe return to play, and the recommendations in the table on return to play after multiple concussions have no evidence to support them. Nor is there any evidence for waking concussed patients every 2 hours at home to see if they are OK. A physician who believes that this level of care is required should admit the patient to a hospital for observation.
Drs. McConnell and Shubrook correctly point out that neuroimaging should be reserved for focal neurologic symptoms, advancing symptoms, or prolonged symptoms as seen in post-concussion syndrome, and they cite a relatively new article to support the use of sertraline in post-concussion treatment—which many of us in primary care sports medicine have been using for years. Overall, however, I was surprised to see such antiquated thought in a review article in The Journal of Family Practice. I hope to see more up-to-date information with practical applications in concussion management, should you cover this topic again.
William Vollmar, MD
Diamantoni and Associates Family Practice
Same-day return to play? Not for young athletes
I’m a certified, licensed athletic trainer who often works with family physicians when dealing with high school athletes, and was excited to see an article on concussion in the August 2009 issue. After reading the article by Drs. McConnell and Shubrook, however, I felt it was important to voice my concerns about some of the statements they made.
The authors cite the position statement of the National Athletic Trainers’ Association (NATA),1 which I co-authored, and indicate that “concussion scales are a useful guide for making treatment decisions.” The NATA paper does not state this. Rather, it discusses 3 methods related to grading, and recommends either grading after symptoms resolve or using adjunct assessment tools to plan individualized injury management.
Of greater concern is the statement regarding return to play (RTP) after sports concussions. The authors suggest that athletes with a grade 1 concussion can return to the field in 15 minutes if they are asymptomatic, citing American Academy of Neurology (AAN) guidelines. But the recently published summary statement based on the 2008 International Conference on Concussion in Sport in Zurich2 states that, “It is not appropriate for a child or adolescent athlete with concussion to RTP on the same day as the injury regardless of the level of athletic performance.”
The statement further notes that “concussion modifiers apply even more to this population than adults and may mandate more cautious RTP advice.” The concussion modifiers referred to include individuals under the age of 18 and loss of consciousness, both of which are discussed in the hypothetical case presented in the article.
Even with adult athletes, the recommendations from Zurich for same-day RTP indicate that this should occur only in instances in which there are team physicians present and sufficient resources, including access to neuropsychologists, neuroimaging, and sideline neurocognitive assessments.
Tamara Valovich McLeod, PhD, ATC
Arizona School of Health Sciences
DRS. McCONNELL AND SHUBROOK RESPOND
We appreciate these thoughtful comments, and recognize that practitioners from many specialties treat concussions—family medicine, emergency medicine, sports medicine, internal medicine, and neurology, among others. Many of these specialties have their own recommendations for diagnosing and treating concussion. Likewise, there are several diverse published guidelines, most notably those of the First International Conference on Concussion in Sport in Vienna,1 which are used to diagnose concussion.