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The management of concussion has evolved significantly over the past decade, and more recently has received significant media attention, particularly as it relates to professional football codes. Many of the concussion guidelines published 30 years ago were predominantly opinion-based, and favoured mandated periods of abstinence from sport, without consideration of individual athlete recovery times. As the science of concussion has developed, significant new data have enabled the formulation of evidence-based guidelines for the management of concussion in sport, culminating in the guidelines published after each International Symposium on Concussion in Sport meeting in Vienna (2001), Prague (2004) and Zurich (2008).1 Current guidelines focus on clinical assessment of recovery to allow graded return to sport. In the absence of a single gold standard direct measure of recovery, combined clinical measures are used (ie, symptoms, balance and cognitive function).
The paper by Price et al2 examines the extent of practical application of these guidelines into professional football in the UK. They found that there was a lack of consensus among the football clubs’ medical personnel regarding concussion management. Moreover 27.8% of the respondents were not even aware of the Zurich guidelines. As the Zurich guidelines were published simultaneously in 11 sports medicine and neuroscience journals in 2009, it is both surprising and disappointing that awareness of the guidelines is not greater among sports doctors. It is apparent that formulation and publication of the guidelines is ineffective without sufficient dissemination and implementation of the guidelines at all levels of sport. This is a major challenge for sports throughout the world. Methods of knowledge transfer are the subject of our (and others) ongoing research.3 ,4
Price et al present a summary of the key elements of concussion management. It is apparent, however, that there may be some confusion in the sports medicine community with regard to some elements of the Zurich guidelines. One common area of confusion relates to the use and interpretation of sideline assessment tools, simple cognitive measures, computerised cognitive screening and formal neuropsychological assessment. Price et al identify the use of Sport Concussion Assessment Tool 2 (SCAT2) and computerised cognitive screening test (ImPACT) as equivalent measures for the purposes of concussion guideline compliance. They are not equivalent, and should not be used interchangeably.
SCAT2 is a sideline assessment toolthat incorporates a symptom checklist, a brief assessment of orientation, memory and concentration, and some simple balance and coordination tests. Its primary goal is to assist with the diagnosis of concussion on the sideline, with a secondary use of monitoring recovery over time. However, SCAT2 is a tool used in addition to a medical assessment, and is not a stand-alone instrument. There is no extant instrument that obviates the need for clinical assessment.
Cognitive assessment is an important element of concussion management. The primary role of cognitive assessment is to monitor recovery following concussion. While it is an important component of assessment it should not replace clinical medical assessment.5 There are many and varied ways to assess cognition in concussion, each with a different level of complexity and reliability. The cognitive test element of SCAT2 is an example of a simple paper and pen test. While it contains some brief cognitive screening tools, it is not a complete cognitive assessment. The next level of cognitive testing involves screening computerised cognitive tests (eg, CogSport and ImPACT). These test batteries are not suitable for on-field diagnosis of concussion, but are screening tools for cognitive assessment. They have utility in monitoring athletes diagnosed with concussion, especially when used with baseline preseason assessments. However, computerised cognitive tests are not as reliable as the ultimate level of cognitive testing, the formal neuropsychological assessment performed by a neuropsychologist expert in the assessment of concussed athletes. Choosing the appropriate neuropsychological tests, and interpreting them correctly, is both a science and an art, and is not supplanted by computerised testing. Most athletes with concussion will not require full neuropsychological assessment. It is reserved for the athlete with prolonged symptoms or concussion modifiers (as defined in the Zurich statement).
It is important to understand the functions and limitations of sideline assessment tools, computerised assessment tools and formal neuropsychological assessment in the management of concussion. They are not interchangeable, but are tools used as part of a comprehensive clinical assessment in concussion management. Symptoms, neurological function, balance testing and response to exercise are all critical elements of concussion assessment, and are monitored in addition to (not ‘instead of’) cognition.
The development of the Zurich guidelines is a process in evolution. As ongoing research provides new information on the science of concussion, these data will be incorporated into the next iteration of the guidelines, and it will be the responsibility of the International Concussion in Sport Group to improve the dissemination and adoption of these guidelines by the International Sports Community at the professional, amateur, community and junior levels.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Commissioned; externally peer reviewed.