American Medical Society for Sports Medicine Position Statement: Concussion in Sport

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Executive SummaryPurpose of the StatementTo provide an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion.To establish the level of evidence, knowledge gaps, and areas requiring additional research.Importance of an AMSSM StatementSports medicine physicians are frequently involved in the care of patients with sports concussion.Sports medicine physicians are specifically trained to provide care along the continuum of sports concussion from the acute injury to return-to-play decisions.The care of athletes with sports concussion is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. Competence should be determined by training and experience, not dictated by specialty.While this statement is directed toward sports medicine physicians, it may also assist other physicians and healthcare professionals in the care of patients with sports concussion.DefinitionConcussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiologic process. Concussion is a subset of mild traumatic brain injury that is generally self-limited and at the less severe end of the brain injury spectrum.PathophysiologyAnimal and human studies support the concept of postconcussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell.Experimental evidence suggests the concussed brain is less responsive to usual neural activation, and when premature cognitive or physical activity occurs before full recovery the brain may be vulnerable to prolonged dysfunction.IncidenceIt is estimated as many as 3.8 million concussions occur in the US per year during competitive sports and recreational activities; however, as many as 50% of concussions may go unreported.Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer, and basketball.Risk Factors for Sports-related ConcussionA history of concussion is associated with a higher risk of sustaining another concussion.A greater number, severity, and duration of symptoms after concussion are predictors of a prolonged recovery.In sports with similar playing rules, the reported incidence of concussion is higher in females than males.Certain sports, positions, and individual playing styles have a greater risk of concussion.Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury.Preinjury mood disorders, learning disorders, attention deficit disorders (ADD/ADHD), and migraine headaches complicate diagnosis and management of concussion.Diagnosis of ConcussionConcussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion.Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations.Standardized assessment tools provide a helpful structure for the evaluation of concussion, although limited validation of these assessment tools is available.‘Sideline’ Evaluation and ManagementAny athlete suspected of having a concussion should be removed from play and assessed by a licensed healthcare provider trained in the evaluation and management of concussion.Recognition and initial assessment of concussion should be guided by a symptom checklist, cognitive evaluation (including orientation, past and immediate memory, new learning, and concentration), balance tests, and further neurologic physical examination.While standardized sideline tests are a useful framework for examination, the sensitivity, specificity, validity, and reliability of these tests among different age groups, cultural groups, and settings is largely undefined. Their practical usefulness with or without an individual baseline test is also largely unknown.

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