MD Group Says Specialist Should Review Concussions

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Athletes of all ages who are suspected of suffering a concussion should be evaluated by a specialist before they return to sports, a major doctors group said Monday in the latest sign of concern over potential lasting damage from head injuries.

The statement by the American Academy of Neurology follows rules already adopted in college sports and pro football aimed at preventing and better treating blows to the head in competition. Research involving NFL players has suggested repeated concussions may have long-term consequences, such as dementia and Alzheimer's disease.

Doctors want to get the message "to the athletes, their parents and their coaches that a concussion is not just a ding, or getting your bell rung, but it is an injury to the brain," said Dr. Mark Halstead of Washington University.

Concussions "need to be treated as if they are a big deal. The brain is pretty important."

The neurology academy is the most authoritative medical group when it comes to concussions. And its new advice sweeps across all ages and types of athletes. The academy also calls for a certified athletic trainer at every sports event and even practices where there is risk of concussion, something that would be a dramatic change in youth sports.

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Major U.S. sports leagues, meanwhile, have gained attention for their recent efforts to cut down on head injuries and improve treatment for concussions.

Last December, after reports of research on older NFL players suggested a higher risk for Alzheimer's, the NFL toughened up its return-to-play rules. It expanded the list of concussion symptoms that would keep a player off the field, and teams were ordered to consult a neurologist on return-to-play decisions.

In March, the National Hockey League banned shoulder hits to the head from a player's blind side. Major League Baseball is setting up a new advisory panel on concussions, which will consider a seven-day disabled list just for head injuries. And in college sports, the NCAA's board of directors in April approved new rules on concussions, saying players must be evaluated by a medical professional experienced in dealing with such injuries.

Dr. Jeff Kutscher, chair of the academy's sports neurology section, said the academy's current guidelines on managing concussions and when to return to play were written in 1997, and experience since then has shown they are inadequate. Experts hope to publish new guidelines by 2012, following a careful review of published studies, he said.

The group's new statement released Monday is meant to offer guidance in the meantime for child and adult athletes, he said. Key points include:

- An athlete suspected of suffering a concussion should be removed from competition until evaluated by a doctor trained in assessing and treating sports concussions. Symptoms like unconsciousness, unsteadiness, problems with memory or concentration, dizziness or headache are warning signs, Kutscher said.

- No athlete with symptoms should be allowed to take part in sports.

- After a concussion, a neurologist or another physician with proper training should be consulted before the athlete is allowed to return to sports.

- A certified athletic trainer should be present at all sports events, including practices, where athletes are at risk for concussion. This recommendation is especially crucial for middle school and younger children, for whom such trainers are rarely used, Kutscher said.

Certified athletic trainers now work at about 40 percent of the nation's high schools and are rarely provided for athletes in younger grades, said Kevin Guskiewicz of the University of North Carolina, Chapel Hill.

It would be a struggle to find enough of them to cover high schools and also programs for younger athletes, he said.

Kutscher said that if a certified athletic trainer is not available to a school, perhaps contact sports should be avoided.

Guskiewicz, who was lead author of the National Athletic Trainers' Association statement on managing concussions, said athletic trainers are well positioned to diagnose concussions in school sports because they know the students so well. They can then make referrals to doctors for care.
In an interview, Kutscher said while a physician with specialized training is preferable for the tasks identified in the guidelines, a doctor without such training could be used if necessary.

In August, the American Academy of Pediatrics released a report on dealing with sports concussions in children. It said an athlete who has suffered a concussion should be evaluated by "a health care professional, ideally a physician with experience in concussion management," and get medical clearance before returning to the sport.

Halstead co-wrote that report. He said he would "love for every single concussion to be evaluated by a physician," but that in rural areas, a nurse practitioner or physician assistant "may be the best we have."

He noted that a Washington state law passed last year, similar to those that have followed in several states, says that athletes younger than 18 can't return to the sport without clearance from a licensed health care provider, not necessarily a physician.

Kutscher said concussion is serious enough to call for an MD.

Apart from the pediatrician report, USA Football, the sport's national governing body at the youth and amateur levels, worked with federal authorities to produce a video about concussions that is now part of its coaching certification exam.

In September, the U.S House voted to have experts draw up with federal guidelines on handling concussions in school-aged children. The bill awaits further action.

Kutscher pointed to recent studies that suggest long-term consequences like decreased mental ability, dementia, depression, anxiety and changes in personality as helping draw attention to the risk of concussions.

It's long been known that repeated head blows can cause brain degeneration in boxers, he said, but "the degree to which it appears to be happening in other contact sports ... is the new thing."
Another factor is "a change in how society views it too, which I think certainly started at the top, with the attention the NFL was getting," he said. "That has filtered down to the other levels."