SAN DIEGO—The American Academy of Neurology (AAN) has released an evidence-based guideline for the assessment and management of athletes with concussion. This new guideline replaces the 1997 AAN guideline on the same topic. The new guideline was announced at a press conference at the 65th Annual Meeting of the AAN and was published in the March 18, 2013, online issue of Neurology.

"With over a million athletes experiencing sports-related concussion per year in the United States, the AAN is pleased to release this evidence-based guideline," said lead author Christopher C. Giza, MD, from the David Geffen School of Medicine and Mattel Children's Hospital at UCLA.

The guideline was developed using an evidence-based process and was multidisciplinary in nature, including neurologists and a panel of professionals from other specialties who are involved in the care and assessment of athletes with sports concussions. "These recommendations are the best summation of available science regarding the assessment and management of sports concussion," Dr. Giza said.

"One of the most important recommendations from this guideline is that an athlete who sustained or is suspected of sustaining a concussion should be removed from play that day and then be assessed by a licensed health care provider with expertise in management of concussion," Dr. Giza said.

Another important component that came out of the evidence was the effect of concussion on youth. "Evidence suggests that high school-age individuals with concussion take longer to recover than their older professional counterparts, and so they should be managed more conservatively." The guideline committee also found a dearth of evidence on concussion under the age of high school and this, they said, was an area for future investigation.

"Individuals with suspected injury should be removed from contact risk activity after concussion," Dr. Giza said. "The evidence is really sparse for complete cognitive restriction after concussion—complete cognitive rest. The guideline recommends that athletes be removed from sports activity that would put them back at contact risk. An important distinction of this guideline from the 1997 guideline is that it moves away from the grading system of concussion. We don't find that the evidence supports trying to rate the concussion at the moment of impact and determine how severe it was or how long a return to play would be. In this case the assessment of concussion would be done individually with multiple diagnostic tools, and the management plans are individualized because there are different factors that contribute to how long an athlete might recover from concussion."

Among the sports in the studies evaluated, risk of concussion is greatest in football and rugby, followed by hockey and soccer. The risk of concussion for young women and girls is greatest in soccer and basketball.

According to the guideline:

• An athlete who has a history of one or more concussions is at greater risk of being diagnosed with another concussion.

• The first 10 days after a concussion appear to be the period of greatest risk of being diagnosed with another concussion.

• There is no clear evidence that one type of football helmet can better protect against concussion compared with another kind of helmet. Helmets should fit properly and be well maintained.

• Licensed health care professionals trained in treating concussion should look for ongoing symptoms (especially headache and fogginess), history of concussions, and younger age in the athlete. Each of these factors has been linked to a longer recovery after a concussion.

• Risk factors linked to chronic neurobehavioral impairment in professional athletes include prior concussion, longer exposure to the sport, and having the APOE ε4 gene.

• Concussion is a clinical diagnosis. Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychologic testing (paper-and-pencil and computerized), and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis.

• Signs and symptoms of a concussion include headache and sensitivity to light and sound; changes to reaction time, balance, and coordination; changes in memory, judgment, speech, and sleep; loss of consciousness or a "blackout" (occurring in less than 10% of cases).

"If in doubt, sit it out," said Jeffrey S. Kutcher, MD, from the University of Michigan Medical School in Ann Arbor and a coauthor of the guideline. "Being seen by a trained professional is extremely important after a concussion. If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor."

The new AAN guideline has been endorsed by the National Football League Players Association, the Child Neurology Society, the National Association of Emergency Medical Service Physicians, the National Association of School Psychologists, the National Athletic Trainers Association, the American Football Coaches Association, the National Academy of Neuropsychology, and the Neurocritical Care Society.

—Glenn S. Williams
Vice President/Group Editor

AAN Releases Updated Sports Concussion Guideline