As the science surrounding concussion evolves, so must the medical care
All concussions are serious. Yet balancing what we know about concussion,
neurological function, and brain health with what we don’t know
can sometimes be a tightrope walk for a sports neurologist. With the science
of concussion evolving rapidly, there is no single, universally accepted
consensus definition for it. The lack of clear definitions can lead to
a wide range of opinions on diagnosis and treatment for patients. For
example, a short time ago, strict bed rest was considered the gold standard
for sport-related concussion recovery in athletes. But a new consensus
statement from a panel formed by the
British Journal of Sports Medicine (BJSM) now rebuts that recommendation – with solid scientific reason: strict
rest might slow concussion recovery after a sport-related concussion,
not enhance it.
As one can imagine, rapidly evolving neurological science can lead to what
seems like wide swings in treatment recommendations, especially to patients
and the public who are on the outside looking in. Concussion in the news
is a hot topic and an even more concerning one for those at risk and their
caregivers. But I want to assure people that they’re in the right
hands. A multitude of bright scientific minds constantly and passionately
assess what we know about the brain against what we don’t and adjust
when more information is revealed. That is a good thing for patients and
the public. It’s how the science of medicine should work.
Not so long ago in neurological science history, concussion was classically
thought to be a functional brain disturbance that was temporary and not
associated with actual structural brain damage. However, more recent scientific
discovery has revealed that advanced imaging in some individuals with
clinically uncomplicated concussive injury may reveal structural changes.
We’re still working out whether or not the changes are temporary
or permanent. And, of course, we must reinforce the reality that structural
changes do not necessarily mean there is any impairment in function.
From these earlier neurological concepts came a traditional default position
for early concussion management that can be categorized as “watchful
waiting” – keeping the athlete on activity restriction and
watching for symptom resolution or escalation. But, as the BJSM consensus
statement suggests, this approach may not work best for sport-related
concussions and may slow an athlete’s recovery. Instead, an individualized
symptom management and return-to-play approach should be considered. As
treating physicians, sports neurologists must balance what we know to
be true about the spectrum or continuum of concussion symptoms in a patient
with their age and the circumstances surrounding the concussion they sustained.
In recent years, the concept of a graduated return to play protocol has
been well accepted. But even a graduated protocol should be considered
and possibly adjusted based on an athlete’s unique circumstances.
Ideally, recovery and return-to-play recommendations should not be one-size-fits-all
but tailored to the individual athlete. And with newer information regarding
the benefits of exercise, the approach to recovery and return to play
becomes even more nuanced. Even within the first several days after a
concussive injury, many athletes benefit from instituting a monitored/controlled
exercise program as part of their concussion treatment, before officially
entering the return to play phase. That is, they may still be symptomatic,
but benefit from controlled exertion and exercise to assist the brain
in recovery. We typically begin the return to play process when an athlete
is asymptomatic. The tenets of a sound return-to-play protocol include
that: the athlete is concussion symptom-free, has a normal physical examination,
has returned to a normal neurological baseline (more on this below), and
can tolerate the phased approach well, without reigniting concussion symptoms.
Sport-related concussion is a treatable condition and should be approached
as such. Physical exertion and exercise as medicine is an example of how
our approach has evolved beyond watchful waiting. Armed with the right
tools and even more evidence than ever before to support their use, athletes
and their loved ones can take comfort in knowing we have their best brain
health interests at heart.