Concussion Treatments Unproven: Updated Guide Changes Rest Time

TORONTO - An international panel of experts has issued an updated consensus statement on evaluating and treating sports-related concussions, which includes some tweaks on managing the brain injury and a discussion on the possible link with chronic traumatic encephalopathy, or CTE.

The goal of the statement is to update doctors, athletic therapists and other health-care providers on the best way to diagnose a concussion at a sporting event and to manage the patient's recovery over time.

"Concussion is one of the most complex injuries to diagnose and treat, and our understanding of concussion is constantly evolving," said panel co-chair Dr. Willem Meeuwisse, leader of the University of Calgary's Brain Injury Initiative.

"This document attempts to give health-care professionals a road map to what we believe will provide the best patient outcomes."

The paper is also intended to help advise sports federations — among them those representing hockey, football and soccer — on how to adapt the guidelines to their individual sport.

Published in the April issue of the British Journal of Sports Medicine, the statement was penned following a meeting of 32 experts, including several Canadians, in Zurich last November. Experts have met roughly every four years since 2001, and this is the fourth consensus document to be issued.

One change in the updated version is that an athlete who has suffered a concussion may not always have to rest their brains and bodies as long as previously thought before returning to cognitive and physical activities.

Based on the latest studies, the panel agreed that some of the current treatment protocols — including extended rest — are largely unproven and may not be ideal after the first week following injury.

They suggest that a gradual return to school, social and physical activities is "a sensible approach," but that athletes should receive medical clearance before returning to competition.

"Typically, we see around 80 per cent of athletes will be recovered within about a week to 10 days," Meeuwisse said Monday from Calgary.

"What's changed is in the past, we would say if you're not better, well 'get more rest.' And now we're recognizing that in the 20 per cent or so who are not recovered by 10 days, that often there are other things that are going on that require a more detailed assessment and often can benefit from rehabilitation."

Even some light exercise can be beneficial after the acute phase of concussion has passed, recent research now suggests.

Dr. Paul Echlin, a sports medicine physician who treats concussion and also conducts research on the injury, said it's helpful to have experts weigh the research as it evolves over time and disseminate any new knowledge to health providers, athletes of all ages and levels of play, parents and coaches.

"I think it's important that this continue, this centralized and this sequential review of knowledge, and the promotion of when the knowledge does change to pay attention and document it, so there's not multiple entities saying this is the way to proceed on this injury," Echlin said from Burlington, Ont.

"I think having one source is much better than having three or four sources, which sometimes confuses the patient."

After sifting through the latest studies, the panel also confirmed that even the most state-of-the-art helmets and mouth guards do not prevent a concussion, which occurs when the brain is shaken inside the skull, similar to an egg yoke slamming the inside of its shell.

"While some of the newer technology show a reduction in some of the forces that you can measure in a lab, we're not seeing any reduction in concussions, which means it's not probably having the degree of effect on how the brain moves inside the skull, which is really the issue," Meeuwisse said.

"And some people are concerned that putting more padding on is going to let people hit harder without hurting as much, but yet may have as much or more brain effect," he said.

As the consensus statement says: "An important consideration in the use of protective equipment is the concept of risk compensation ... where the use of (this) equipment results in behavioural change, such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates."

While it's advisable to wear a mouth guard because they prevent dental and facial injury, the panel concluded the devices do not lower the risk of sustaining a concussion due to a blow to the head.

And despite all the media attention about the brains of some deceased athletes showing evidence of CTE, the experts say there is not enough evidence to conclude that repeated concussions cause the progressively destructive neurological disease.

"It's a recognition that this science is in a very early stage of its development," Meeuwisse said.

"If you look at the scope of concussion, you have millions of sport-related concussions happen every year and yet we have a very small, isolated number of CTE (cases)."

"Concussion alone has not been shown to (have) a direct cause-and-effect relationship. So it's not the case that if you get hit in the head that you're going to get CTE."

Meeuwisse said there may be other factors, such as genetics or environment, that make some people with a history of repeated concussions susceptible to CTE, while others with multiple brain-shaking knocks to the head are not.

"We don't know, for example, how many of those (CTE brain) changes would occur in people who've never had a concussion," he said.

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