Future Advances and Areas of Future Focus in the Treatment of Sport-Related Concussion

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The end of the beginning

The critical issues in the clinical management of sports concussion include confirming the diagnosis, differentiating concussion from other pathologies (particularly structural head injury), and determining when players have recovered so that they can be safely returned to competition. When expressed in this fashion, the management process seems simple. Yet the occurrence and management of this injury provokes more debate and concern than virtually all other sports injuries combined.

In the past

Opening the chamber of secrets

In many ways, elite sport has been its own worst enemy in this field. The sight of concussed professional athletes returning to play on the day of injury in many sports globally6 gives the public the wrong perception of the seriousness of this injury. Although it is broadly accepted that all athletes, regardless of their level of participation, should be managed using the same return-to-play paradigm, elite teams have far greater resources such as access to emergent neuroimaging, immediate

Same-day return to play

The basic management principles, namely full clinical and cognitive recovery before consideration of return to play, should be followed. This approach is supported by the major published guidelines such as the American Academy of Neurology, US Team Physician Consensus Statement, US National Athletic Trainers Association Position Statement, and the Zurich Consensus statement.1, 3, 4, 5

There is published evidence that some professional American football players are able to return to play on the

The black dog of depression

Mental health issues (such as depression) have been reported as a long-term consequence of sports-related concussion, occurring in approximately 11%, with a possible association with recurrent concussion.9 It is important to examine the wider perspective, because depression and anxiety symptoms occur in 15% to 60% of patients following traumatic brain injury from any cause.10, 11, 12, 13 Neuroimaging studies using functional magnetic resonance imaging and other neuroimaging modalities suggest

Punch-drunk athletes?

Recent cross-sectional descriptive epidemiologic studies have suggested an association between repeated sports concussions during a career and late-life cognitive impairment.19 Similarly, case reports have noted anecdotal cases in which possible neuropathologic evidence of chronic traumatic encephalopathy was observed in retired football players as well as other sportsmen, such as boxers.20, 21, 22, 23, 24

Major methodological flaws exist in these observational studies, and the putative

Little adults or different management strategies for children?

It was accepted by the Zurich international consensus group that the adult athlete evaluation and management recommendations could be applied to children and adolescents down to the age of 10 years with a few important differences.1 Younger than that age, children report different concussion symptoms than adults and require age-appropriate symptom checklists as a part of the assessment. When assessing the child or adolescent athlete with a concussion, the health care professional needs to

Prevention is better than cure

Consideration of rule changes to reduce the head injury risk may be appropriate if a specific mechanism is implicated. An example of this is in football (soccer), for which published studies show that upper limb to head contact in heading contests accounted for approximately 50% of concussions.45 By penalizing such contact and enforcing the rules, the risk of injury has been substantially reduced.46, 47

There is no good clinical evidence that currently available protective equipment (especially

Educating the masses

Because the ability to reduce the effects of concussive injury after the event is minimal, the education of athletes, colleagues, and the general public is a mainstay of progress in this field. All people involved in athlete care, including referees, administrators, parents, coaches, as well as the athletes themselves, must be educated regarding the importance of injury and the principles of safe return to play. However, in spite of the efforts by sports to promulgate such information, evidence

Where to now?

There are several areas of focus at the present time that require resolution. The role of the Concussion in Sport group as an international forum for research exchange and in the development of consensus guidelines cannot be underestimated. In specific countries, such as the US, local guidelines have had a similarly important role in educating medical staff but have yet to translate into mainstream community education. The engagement of mainstream neuroscience is important, but, rather than

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    Financial disclosure: the author has received research funding and conference support from the National Health & Medical Research Council of Australia, the Australian Research Council, the International Rugby Board, Victorian Department of Health, Australian Sports Commission, the International Olympic Commission, Fédération Internationale de Football Association, and CogState Inc.

    No reprints will be available.

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