Last updated December 18, 2021

Evaluation and Management of Concussion in Sports

RECOMMENDATIONS

Preparticipation counseling

School-based professionals should be educated by experienced licensed health care providers (LHCPs) designated by their organization/institution to understand the risks of experiencing a concussion so that they may provide accurate information to parents and athletes. (B)
300167
To foster informed decision-making, LHCPs should inform athletes (and where appropriate, the athletes' families) of evidence concerning the concussion risk factors. Accurate information regarding concussion risks also should be disseminated to school systems and sports authorities. (B)
300167

Suspected concussion

Use of checklists and screening tools

Inexperienced LHCPs should be instructed in the proper administration of standardized validated sideline assessment tools. This instruction should emphasize that these tools are only an adjunct to the evaluation of the athlete with suspected concussion and cannot be used alone to diagnose concussion. (B)
300167
These providers should be instructed by experienced individuals (LHCPs) who themselves are licensed, knowledgeable about sports concussion, and practicing within the scope of their training and experience, designated by their organization/institution in the proper administration of the standardized validated sideline assessment tools. (B)
300167
In individuals with suspected concussion, these tools should be utilized by sideline LHCPs and the results made available to clinical LHCPs who will be evaluating the injured athlete. (B)
300167
LHCPs caring for athletes might utilize individual baseline scores on concussion assessment tools, especially in younger athletes, those with prior concussions, or those with preexisting learning disabilities/attention-deficit/hyperactivity disorder, as doing so fosters better interpretation of postinjury scores. (C)
300167
Team personnel (e.g., coaching, athletic training staff, sideline LHCPs) should immediately remove from play any athlete suspected of having sustained a concussion, in order to minimize the risk of further injury. (B)
300167
Team personnel should not permit the athlete to return to play until the athlete has been assessed by an experienced LHCP with training both in the diagnosis and management of concussion and in the recognition of more severe traumatic brain injury (TBI). (B)
300167

Neuroimaging

CT imaging should not be used to diagnose sport-related concussion (SRC) but might be obtained to rule out more serious TBI such as an intracranial hemorrhage in athletes with a suspected concussion who have  loss of consciousness (LOC), posttraumatic amnesia, persistently altered mental status (Glasgow Coma Scale <15), focal neurologic deficit, evidence of skull fracture on examination, or signs of clinical deterioration. (C)
300167

Management of diagnosed concussion

Return to Play (RTP): Risk of recurrent concussion

In order to diminish the risk of recurrent injury, individuals supervising athletes should prohibit an athlete with concussion from returning to play/practice (contact-risk activity) until an LHCP has judged that the concussion has resolved. (B)
300167
In order to diminish the risk of recurrent injury, individuals supervising athletes should prohibit an athlete with concussion from returning to play/practice (contact-risk activity) until the athlete is asymptomatic off medication. (B)
300167

RTP: Age effects

Individuals supervising athletes of high school age or younger with diagnosed concussion should manage them more conservatively regarding RTP than they manage older athletes. (B)
300167
Individuals using concussion assessment tools for the evaluation of athletes of preteen age or younger should ensure that these tools demonstrate appropriate psychometric properties of reliability and validity. (B)
300167

RTP: Concussion resolution

Clinical LHCPs might use supplemental information, such as neurocognitive testing or other tools, to assist in determining concussion resolution. This may include but is not limited to resolution of symptoms as determined by standardized checklists and return to age-matched normative values or an individual's preinjury baseline performance on validated neurocognitive testing. (C)
300167

RTP: Graded physical activity

LHCPs might develop individualized graded plans for return to physical and cognitive activity, guided by a carefully monitored, clinically based approach to minimize exacerbation of early postconcussive impairments. (C)
300167

Cognitive restructuring

Cognitive restructuring is a form of brief psychological counseling that consists of education, reassurance, and reattribution of symptoms. Whereas there are no specific studies using cognitive restructuring specifically in sports concussions, multiple studies using this intervention for mTBI have shown benefit in decreasing the proportion of individuals who develop chronic postconcussion syndrome.
Therefore, LHCPs might provide cognitive restructuring counseling to all athletes with concussion to shorten the duration of subjective symptoms and diminish the likelihood of development of chronic postconcussion syndrome. (C)
300167

Retirement from play after multiple concussions: Assessment

LHCPs might refer professional athletes with a history of multiple concussions and subjective persistent neurobehavioral impairments for neurologic and neuropsychological assessment. (C)
300167
LCHPs caring for amateur athletes with a history of multiple concussions and subjective persistent neurobehavioral impairments might use formal neurologic/cognitive assessment to help guide retirement-from-play decisions. (C)
300167

Retirement from play: Counseling

LHCPs should counsel athletes with a history of multiple concussions and subjective persistent neurobehavioral impairment about the risk factors for developing permanent or lasting neurobehavioral or cognitive impairments. (B)
300167
LHCPs caring for professional contact sport athletes who show objective evidence for chronic/persistent neurologic/cognitive deficits (such as seen on formal neuropsychological testing) should recommend retirement from the contact sport to minimize risk for and severity of chronic neurobehavioral impairments. (B)
300167

Recommendation Grading

Overview

Title

Evaluation and Management of Concussion in Sports

Authoring Organization

Publication Month/Year

March 18, 2018

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion.

Inclusion Criteria

Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Outpatient, School

Intended Users

Physical therapist, paramedic emt, occupational therapist, athletics coaching

Scope

Assessment and screening, Management

Diseases/Conditions (MeSH)

D001924 - Brain Concussion, D000070642 - Brain Injuries, Traumatic

Keywords

postconcussion impairments, concussion, sports injury, traumatic brain injury

Source Citation

Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Christopher C. Giza, Jeffrey S. Kutcher, Stephen Ashwal, Jeffrey Barth, Thomas S.D. Getchius, Gerard A. Gioia, Gary S. Gronseth, Kevin Guskiewicz, Steven Mandel, Geoffrey Manley, Douglas B. McKeag, David J. Thurman, Ross Zafonte. Neurology Jun 2013, 80 (24) 2250-2257; DOI: 10.1212/WNL.0b013e31828d57dd