SPECIAL COMMUNICATIONS Team Physician Consensus Statement Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement* DEFINITION SUMMARY Concussion or mild traumatic brain injury (MTBI) is a pathophysiological This document provides an overview of select medical issues that are process affecting the brain induced by direct or indirect biomechanical important to team physicians who are responsible for athletes with forces. concussion. It is not intended as a standard of care, and should not be Common features include: interpreted as such. This document is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the • Rapid onset of usually short-lived neurological impairment, which healthcare professional. Individual treatment will turn on the specific facts typically resolves spontaneously. and circumstances presented to the physician. Adequate insurance should • Acute clinical symptoms that usually reflect a functional disturbance be in place to help protect the physician, the athlete, and the sponsoring rather than structural injury. organization. • A range of clinical symptoms that may or may not involve loss of This statement was developed by a collaboration of six major consciousness (LOC). professional associations concerned about clinical sports medicine issues; • Neuroimaging studies that are typically normal. they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people GOAL and athletes. The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American The goal is to assist the team physician in providing optimal medical College of Sports Medicine, American Medical Society for Sports care for the athlete with concussion. Medicine, American Orthopaedic Society for Sports Medicine, and the To accomplish this goal, the team physician should have knowledge of American Osteopathic Academy of Sports Medicine. and be involved with: • Epidemiology • Pathophysiology EXPERT PANEL • Game-day evaluation and treatment • Post–game-day evaluation and treatment Stanley A. Herring, M.D., Chair, Seattle, Washington • Diagnostic imaging John A. Bergfeld, M.D., Cleveland, Ohio • Management principles • Return-to-play Arthur Boland, M.D., Boston, Massachusetts • Complications of concussion Lori A. Boyajian-O’Neill, D.O., Kansas City, Missouri • Prevention Robert C. Cantu, M.D., Concord, Massachusetts Elliott Hershman, M.D., New York, New York Peter Indelicato, M.D., Gainesville, Florida Rebecca Jaffe, M.D., Wilmington, Delaware *Editor’s Note: The Team Physician Consensus Statement was published W. Ben Kibler, M.D., Lexington, Kentucky in the November 2005 Medicine & Science in Sports & ExerciseÒ without two final corrections. The corrected statement is published here in its Douglas B. McKeag, M.D., Indianapolis, Indiana entirety. Robert Pallay, M.D., Hillsborough, New Jersey Margot Putukian, M.D., Princeton, New Jersey Copyright Ó 2006 by the American College of Sports Medicine (ACSM), American Academy of Family Physicians (AAFP), American Academy of Orthopaedic Surgeons (AAOS), American Medical Society for Sports INTRODUCTION Medicine (AMSSM), American Orthopaedic Society for Sports Medicine (AOSSSM), and the American Osteopathic Academy of Sports Medicine It is essential the team physician understand: (AOASM). • The recognition and evaluation of the athlete with con- 0195-9131/06/3802–0395/0 cussion. MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ • Management and treatment of the athlete with concus- DOI: 10.1249/01.mss.0000202025.48774.31 sion be individualized. 395 Copyright @ 2006 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. • The factors involved in making return-to-play (RTP) TABLE 1. Selected acute signs and symptoms suggestive of concussion. decisions after injury should be based on clinical judgment. Cognitive Somatic Affective • A game-day medical plan specific to concussion inju- Confusion Headache Emotional lability Posttraumatic amnesia (PTA) Fatigue Irritability ries be developed. Retrograde amnesia (RGA) Disequilibrium, dizziness • The need for documentation. Loss of consciousness (LOC) Nausea/vomiting • There is a paucity of well-designed studies of concus- Disorientation Visual disturbances Feeling ‘‘in a fog,’’ ‘‘zoned out’’ (photophobia, blurry/double sion and its natural history. Vacant stare vision) Inability to focus Phonophobia It is desirable the team physician: Delayed verbal and motor responses • Coordinate a systematic approach for the treatment of Slurred/incoherent speech Excessive drowsiness the athlete with concussion. • Identify risk factors and implement appropriate treat- ment. • Assess for adequate airway, breathing, and circulation • Understand the potential sequelae of concussive (ABC’s) injuries. • Followed by focused neurological assessment empha- • Understand prevention strategies. sizing mental status, neurological deficit, and cervical spine status EPIDEMIOLOGY • Determine initial disposition (emergency transport vs • Concussions occur commonly in helmeted and non- sideline evaluation) helmeted sports, and account for a significant number of time loss injuries. Sideline • Published reports indicate concussion injuries occur at a rate of: • Obtain a more detailed history and perform a more • 0.14–3.66 injuries per 100 player seasons at the detailed physical examination. high school level, accounting for 3–5% of injuries • Assess for cognitive, somatic, and affective signs and in all sports symptoms of acute concussion (see Table 1), with • 0.5–3.0 injuries per 1,000 athlete exposures at the particular attention to retrograde amnesia (RGA), collegiate level. posttraumatic amnesia (PTA), and more than brief • Self-report data suggests significantly higher incidence LOC (minutes, not seconds), because of their prognostic of concussion. significance. • Because of under recognition and/or under reporting, • Not leave the player unsupervised the incidence of concussion and its sequelae is un- • Perform serial neurological assessments known. • Determine disposition for symptomatic and nonsympto- matic players, including postinjury follow-up (options PATHOPHYSIOLOGY include return-to-play, home with observation, or trans- port to hospital). • Metabolic changes that occur in the animal model, and • Provide postevent instructions to the athlete and others thought to occur in humans include: (e.g., regarding alcohol, medications, physical exertion • Alterations in intracellular/extracellular glutamate, and medical follow-up). potassium and calcium • A relative decrease in cerebral blood flow in the setting of an increased requirement for glucose (i.e., increased glycolysis). This mismatch in the meta- It is desirable the team physician: bolic supply and demand may potentially result in cell dysfunction and increase the vulnerability of On-Field the cell to a second insult. • Have a plan to protect access to the injured player • Have emergency medical personnel on-site GAME-DAY EVALUATION AND TREATMENT • Have medical supplies on-site for rescue, immobili- It is essential the team physician: zation and transportation [See ‘‘Sideline Preparedness for the Team Physician: A Consensus Statement’’; (1)] • Implement the game-day medical plan specific to con- cussion. Sideline • Understand the indications for cervical spine immobi- • Delineate the mechanism of injury. lization and emergency transport. • Perform a more detailed assessment of cognitive function (e.g., memory, calculations, attention span, On-Field concentration, speed of information processing). • Evaluate the injured athlete on-the-field in a system- • Coordinate the care and follow-up of the athlete atic fashion: with concussion. 396 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org Copyright @ 2006 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. • Discuss status of athlete with parents, caregivers, cer- • Duration of symptoms is a major factor in determining tified athletic trainers and coaching staff within dis- severity, therefore severity of injury should not be closure regulations. determined until all signs and symptoms have cleared. • The treatment of and the RTP decision for the athlete with concussion must be individualized. POST–GAME-DAY EVALUATION AND TREATMENT It is desirable the team physician: It is essential the team physician: • Coordinate a team for concussion management (e.g., physicians, certified athletic trainers, neuropsycholo- • Obtain a comprehensive history of the current concus- sion, and any previous concussion. gists, emergency response personnel). • Discuss status of athlete with parents, caregivers, • Perform a physical examination, including a detailed certified athletic trainers and coaching staff within dis- neurological/cognitive evaluation. closure regulations. • Determine the need for further evaluation and consul- tation. • Determine return-to-play status. RETURN-TO-PLAY (RTP) DECISION It is desirable the team physician: The RTP decision should be individualized, and not based • Coordinate the care and follow-up of the athlete. on a rigid timeline. The team physician is ultimately • Understand the indications and limitations of neuro- responsible for the RTP decision. [See ‘‘The Team Physician psychological testing. and Return-To-Play Issues: A Consensus Statement’’; (2).]