Concussion Consensus Calls for Caution

When in doubt, take them out. That is the most important message of the new Berlin Consensus Statement on Concussion in Sport.^[1]

Doctors, coaches, trainers, players, and everyone involved in making decisions about players with head injuries must err on the side of caution and remove these players until a specialist can confirm a diagnosis. The consensus statement reflects the wisdom of experts from around the world who came together in Berlin last October to pore over the evidence about sports-related concussions (SRCs) and hash out recommendations. The resulting statement, published online on April 26, 2017, in the British Journal of Sports Medicine, updates and expands on four previous such statements, the oldest of which was published in 2001.

The statement defines SRC as "a traumatic brain injury induced by biomechanical forces." Typically, SRC results from a blow to the head, face, or neck, or elsewhere to the body resulting in impulsive force transmitted to the head.

SRC causes impairment of neurologic function that cannot be explained by drugs or comorbidities. These impairments most often appear quickly, but sometimes evolve over minutes or hours. Usually, no abnormality can be found with standard structural imaging.

The consensus statement lists these possible symptom domains:

Somatic symptoms (eg, headache), cognitive (eg, feeling as if in a fog), and/or emotional symptoms (eg, lability);
Physical signs (eg, loss of consciousness, amnesia, neurologic deficit);
Balance impairment (eg, gait unsteadiness);
Behavioral changes (eg, irritability);
Cognitive impairment (eg, slowed reaction times); and
Sleep/wake disturbance (eg, somnolence, drowsiness).

Injuries Not Always Easy to Spot, and Restrictions Not Always Easy to Enforce

The constantly shifting, chaotic circumstances of a sporting match can make it difficult to witness concussions when they happen. If you glance at your phone or someone walks between you and the play, you can miss something crucial.

Caught up in the excitement and pressure of competition, players and coaches may feel an incentive to minimize symptoms. As medical professionals, it is our job to make sure concussion concerns get priority over all other considerations.

In elite competitions, we can employ spotters who constantly review video to watch for possible injuries and resulting symptoms. In my own experience covering professional soccer, I find this invaluable and have often pulled players out on the basis of clips texted to me by these spotters.

In athletic competitions that do not have such resources, we must call on coaches, referees, and players to be vigilant. When players experience loss of consciousness, seizure, or severe ataxia, they should stop playing and go for evaluation from medical professionals in a quiet setting.

I like to point out to coaches that I have never seen an athlete knocked unconscious who comes back and plays a good game. If players do not stop playing then and there, they wind up in the hospital at the end of the game. So when they lose consciousness, I do not need 3 minutes—I need 4 seconds to pull that player out.

Likewise, signs of seizure are signs of damage. In my experience, that damage will always impair a player's performance. And if the player cannot walk straight or looks punch-drunk, the player will not be able to participate successfully at least for the rest of that day.

When players show less significant symptoms or have simply been hit hard, they can be evaluated on the sideline by a trained professional using the Sports Concussion Assessment Tool, version 5 (SCAT5).^[2] The SCAT5 is designed to detect changes in orientation, mentation, intelligence, judgment, or attention span. If no one is able to administer the SCAT5 on the sidelines, the athlete should be taken to an emergency department or another facility where that expertise is available.

Although we still do not know the exact relationship between concussion recovery and physical or cognitive activity, our best advice is for athletes to rest for 24-48 hours and then begin only those activities that do not cause or worsen symptoms, gradually increasing the intensity over a period of days or weeks before returning to sport.

Prevention Is the Best Approach

Of course, none of this vigilance would be necessary if we could prevent concussions in the first place. Many proposals, such as using mouth guards, neck strengthening, or various types of headgear, have not yet been shown to reduce the risk for concussion. It is difficult to study the effects of helmets in such sports as football, where they are already mandatory, but we have enough evidence to require them in skiing and snowboarding.

We also know that rules can help. Tackling in football and body-checking in hockey should not be allowed in children's sports, and referees should dole out red cards for high elbows in soccer heading duels.

Apart from that, some training in technique can help. When I played football, we kept our helmets away from our opponents and used our shoulders to tackle. Now the helmet is used as part of the tackling, and we should reverse course.

In soccer, most concussions occur in player-to-player collisions. Players must learn when it is not tactical to throw their heads around because they are increasing the risk not only to themselves but also to other players.

Children up to age 10 years should avoid heading the ball in soccer. Some have argued that players can become more effective, or even reduce concussion risk, if they practice heading at a younger age. I have not seen evidence of that. But I do know that if players spend more time with the ball on the ground, they have less chance of injuring their heads.

As physicians, we cannot attend every pickup basketball game, Little League practice, or Pop Warner football tryout. So we must go beyond administering these protocols ourselves and educate players, referees, and coaches. We must train a new generation of coaches to become ambassadors for caution and moderation, to protect the generation of players in their care.

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