The new concussion consensus – five concepts every health professional should understand.

The Concussion in Sport Group (CISG) has just released its new consensus statement from the 5th International Conference on Concussion in Sport held in Berlin late last year. The consensus is the product of thirty-five experts from medical and sports organisations considering over sixty thousand published articles so, to put it very mildly, if you’re a health professional who deals with concussion, you really do need to get your head around it.

We’d strongly advise you sit down with a cup of tea and have a read through the full document yourself sometime – you can download it for free here – but in the interests of starting a discussion, we’ve highlighted some of the game changing revelations for us at The Studio’s concussion service.

Side-line concussion evaluation isn’t getting any easier.
According to the new consensus statement, there’s still no perfect diagnostic test or marker clinicians can rely on for an immediate diagnosis of concussion. The problem is, as it’s a functional disturbance, it doesn’t show up using standard neuroimaging techniques – so we’re still looking for concussion’s symptomatic footprints, rather than hoping to spot the beast in the flesh.

There’s some promising work being done on sensor- and video-based systems aimed at detecting the forces necessary to cause concussion, but they don’t yet accurately measure the forces being exerted on the brain itself, and so aren’t of much use… yet.

According to the CISG, given our current understanding of concussion, it’s best to be super-conservative when it comes to side-line evaluations. “Sport-related concussion is often an evolving injury, and signs and symptoms may be delayed, erring on the side of caution (i.e. Keeping an athlete out of participation where there is any suspicion of injury) is important.” In other words: you’re far better off wishing you hadn’t removed a player than wishing you had!

Absolute rest is overkill.
We’ve known that rest is best for concussion patients for a long time now, but what’s new for the 2017 consensus statement is that it doesn’t need to be complete rest.

The consensus says, “After a brief period of rest during the acute phase (24-48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom exacerbation thresholds.”

They go on to say, “closely monitored active rehabilitation programmes involving controlled sub-symptom threshold submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery.”

Remember to re-think.
The Berlin expert consensus discusses the idea of “persistent symptoms”, which is the failure of normal clinical recovery after 10-14 days (or four weeks for children). It’s a slightly nebulous concept which they say “doesn’t reflect a single pathophysiological entity, but describes a constellation of non-specific, post-traumatic symptoms”.

Insanity is often defined as repeatedly doing the same thing over and over again and expecting different results. Indeed, if your concussion treatment plan isn’t working after 10-14 days, it seems pretty rational to try something new.

As far as what new thing to try, the CISG suggest a three-sided strategy: a symptom limited aerobic exercise programme in patients with autonomic instability or physical deconditioning, targeted physical therapy in patients with cervical spine or vestibular dysfunction, and cognitive behavioural therapy to deal with any persistent mood or behavioural issues.

We got to meet SCAT5
The Berlin conference saw the release of the SCAT5 concussion assessment tool, an updated and enhanced version of the SCAT3 tool (there was no SCAT4 – who knows why!).

The new SCAT takes an “if it ain’t broke don’t fix it” approach, so if you’ve used the previous version, you should find the new one fairly intuitive. However, they’ve added fifteen new features including a Rapid Neurological Screen consisting of a cervical exam, speech and reading tests, balance, gait, visual tracking and finger to nose tests.

Go easy on the drugs
The CISG is lukewarm on the use of drugs to rehabilitate concussion, saying there’s “limited evidence to support the use of pharmacotherapy” and adding that if it is used, an important consideration in return to sport is that concussed athletes should be free from concussion related symptoms *and* not taking any medications that may mask or modify those symptoms.

On the whole, the new consensus is another significant step forward, but also a sobering reminder of how much we still don’t know about concussion. The document is littered with suggestions for further research and references to gaps in our understanding of concussion – notably the still uncertain relationship between concussion and chronic traumatic encephalopathy (CTE). They say “the science of concussion is incomplete and therefore management and return-to-play decisions lie largely in the realm of clinical judgement”. That may change when the next consensus statement is released in December 2020, but for now it’s really just a matter of staying up-to-speed as best you can and being conservative.