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  • Revised Pediatric Concussion Guidelines Address Assessment, Return-to-Play, More

    The revised recommendations on pediatric sports-related concussions (SRC) from the American Academy of Pediatrics (AAP) aim to strike a careful balance: while the report emphasizes that "each concussion is unique," it also lays out several broad recommendations on SRC management that touch on assessing recovery, factoring in the circumstances around individual injuries, and understanding the ways state law can impact return-to-play decisions, among other areas.

    The revision—the first in 8 years—comes at a time when SRC reporting is on the rise, with both state legislatures and national media paying increased attention to the effects of repeated mild traumatic brain injury (mTBI) on the human brain. Authors of the AAP report write that while the brighter spotlight is welcome, "underreporting by athletes with SRC remains a large concern," and the general increase in the number of children and adolescents participating in youth sports likely will result in more SRCs, which are currently estimated to happen at the rate of 1.1 million to 1.9 million annually. The report was published in Pediatrics.

    In terms of which sports pose the greatest SRC risk, things aren't much different from 2010: boys' tackle football still poses the most threat of SRC, with a rate of 0.54 to 0.95 concussions per 1,000 "athletic exposures" (AEs)—games and practices. Next highest was girls' soccer with a 0.30 to 0.73 AE rate, followed by boys' lacrosse and boys' ice hockey. Authors also point to recent research that indicates SRC rates are even higher among athletes 12 and younger, with an overall contact sport concussion rate that was 2.4 times higher than their 13-and-older counterparts.

    In addition to epidemiology, the report covers signs and symptoms, assessment on the field, imaging, neurocognitive testing, acute management, return-to-play decisions, prolonged symptoms, and prevention. The analysis served as the foundation for 9 conclusions and 6 recommendations.

    The conclusions:

    • SRC is "common" in youth and high school sports, and warrants further research.
    • Each concussion is unique, with "a spectrum of severity types and symptoms.
    • Evidence-based guidelines indicate that "conventional neuroimaging" may be used unnecessarily, as most imaging is normal after an SRC.
    • Providers should be familiar with a range of tools to evaluate the athlete after an SRC.
    • Symptoms of the SRC should resolve within 4 weeks postinjury for most athletes.
    • An initial reduction in physical and cognitive activity after SRC can be beneficial, but prolonged restrictions "can have negative effects on recovery and symptoms."
    • The long-term effects of concussion—both single and multiple events—have not been definitively determined.
    • No medications can treat or prevent SRCs.
    • Ceasing participation in sport because of SRC "is an individualized decision that may benefit from consultation with a physician who has experience in recommendations for retirement after SRC."

    The recommendations:

    • Neurocognitive testing should not be the only tool used to make a return-to-play decision.
    • Providers should assume that an athlete who remains unconscious after a head injury also has suffered a cervical spine injury.
    • If an athlete has prolonged symptoms after an SRC, providers should conduct an evaluation for coexisting problems, and make referrals as appropriate.
    • All athletes with a suspected SRC should be removed from play immediately and not allowed to return "until they have returned to their baseline level of symptoms and functioning and completed a full stepwise return-to-sport progression without a return of concussion symptoms." A return to a full academic workload should always precede a return to play.
    • Complete prevention of concussion may be impossible, but cervical strengthening, better equipment design, and sports rule changes may help.
    • Providers need to have a thorough understanding of their states' return-to-play laws and regulations.

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

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