Concussion Consensus: Changing Our Approach

First, let me just start by saying: I am not brave enough to ever defy my dentist, especially as someone with an aggressively dominant gag reflex (no joke, they called me “Hork-up” in hockey because I gagged when I put my mouthguard in).  That being said, my good friend Dr. Bob Ridley Jr., dentist extraordinaire, recently called  me out on Twitter and said that I should update the world on the latest Concussion Consensus Statement, which was released mere days ago. Thus, my night has turned from cuddling with a new puppy and watching playoff hockey, to doing research and gritting my teeth excessively. Thanks Bob. 

Working in a multi-disciplinary clinic with several concussion experts I have learned a lot about concussion management and seen some VERY poorly managed concussions. On that note, lets start with some important concussion soap box tid-bits that I believe should be mentioned before we dive into the new concussion guidelines:

  1. Hockey parent: you are not a medical professional. You can not determine when your son or daughter has a concussion, or when/how they should return to play.  I understand you can’t see the injury, and your little superstar is not in a cast, but for arguments sake lets just play it safe with your kid’s brain.
  2.  Hockey trainer: you are not a medical professional, you are a first responder. It is your job to make sure that when an injury occurs, you get your player to an appropriate medical professional. You should CERTAINLY be involved in the rehabilitation process, but you should not lead it.
  3. Medical Professionals: whether you are a family doc, athletic therapist, physical therapist, dentist, chiropractor, physiatrist, neuropsychologist, or a brain surgeon; you CAN NOT manage concussion alone. Use your colleagues. Set your ego aside. Educate yourself.

Now, on to the meat and potatoes. Recently, the great minds of concussion management converged on Berlin to establish the 5th concussion consensus statement, an update on a previous concussion statement out of Zurich in 2012. Here are some interesting statements:

  • There is insufficient evidence to advocate for a “complete rest phase” in concussion management.
    • Up until now, many healthcare professionals have been advocating for complete mental and physical rest immediately post injury until symptoms resolve to baseline levels. The recommendation is now to rest for an initial 24-48 hours, then implement activity as tolerated, i.e. nothing that flares up the symptoms the athlete is experiencing.
  • In adults, symptoms tend to resolve in 10-14 days, but in children (<18 years) symptoms can take 4 weeks to resolve.
    • The vast majority of symptoms tend to resolve in 10-14 days in adults, but the previous guidelines did not account for children taking longer to have symptom resolution. This factor drastically changes patient education and treatment planning, and will help ensure youth are not rushed back into sport.
  • Baseline testing should NOT be mandatory, but can be helpful in managing and interpreting concussions.
    • Baseline testing in Canada has recently become a hot-button topic, after a popular media outlet published an article about clinics hosing people for unneccesary services, including baseline testing. While there are clinics that use baseline testing inappropriately, it can be very useful to determine what a patient’s “normal” is, and help guide appropriate rehabilitation if a concussion occurs.
  • Concussion interventions for ongoing symptoms should include psychological, cervical, and vestibular interventions. 
    • If an individual is going past regular concussion timelines, it is worth while for them to be assessed in the above areas. Concussions can have psychological impacts, and can also cause neck and vestibular related symptoms. These symptoms should be treated by appropriate professionals who are specifically trained in the management of concussion. I will note: I do not know any individuals who are trained in psychology, spinal, and vestibular rehabilitation. Guess we need to go multi-disciplinary.
  • Active, sub-symptom rehabilitation programs have been shown to be safe and may benefit recovery.
    • Monitored physical activity is safe while an athlete is concussed. Provided they are not increasing their symptoms, it makes sense to have an athlete engage in physical activity while they wait for their brain to catch up.
  • Multi-disciplinary care is the way to go
    • No shock there, when a bunch of smart people get together and talk about anything healthcare related, this is what comes out.

As with everything, I suspect it will take years before these new guidelines take a strong hold in sport, specifically youth sport. Truthfully, the information outlined in the previous Zurich consensus had only recently been understood by sport stakeholders- and some haven’t even gotten that far.

I challenge everyone who reads this post: educate yourself on the consensus statement and correct one person’s concussion misconceptions. It is a hot topic right now, and it is not hard to find yourself in a discussion about concussion. Even if you are just yelling at the god-awful SportNet panel as they spew medical advice: correct someone.

That’s all for now folks! Hope you enjoyed it, as always I welcome comments and questions, feel free to email me at mgoertzenpt@gmail.com if you prefer a private discussion!

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