Conservative Management May Reduce Repetitive Concussions

to play and risk of repeat concussion in collegiate football players:
comparative analysis from the NCAA Concussion Study (1999–2001) and CARE
Consortium (2014–2017)         
McCrea M, Broglio S, McAllister T, Zhou W, Zhao S, Katz B, Kudela M, Harezlak J, Nelson L, Meier
T, Marshall SW, Guskiewicz KM, On behalf of CARE Consortium Investigators. Br J Sports Med. 2019 [Epub ahead of print]
Take Home Message: College football players diagnosed with a concussion are
being managed more conservatively with stricter return-to-play protocols, which
may be related to a lower risk of repeat concussions during a season compared
to 15 years ago.

Over the past 15 years,
an increase in concussion awareness and research has lead to new policies, rule
changes in sport, and enhanced concussion assessment and management protocols. Understanding
how these changes influence outcomes, such as the risk of repeat concussion,
may help support current policies and consensus recommendations. Hence, the
authors compared data from two prospective cohorts to examine if injury
management, return to play (RTP), and risk of repeated concussions among
collegiate football players changed over 15 years. Specifically, the authors
used data from the NCAA Concussion Study (1999–2001) and the Concussion Assessment, Research and Education (CARE) Consortium
(2014–2017). The NCAA Concussion Study included 2,905 NCAA football players
from 25 NCAA Division I, II and III universities from 1999 to 2001. Athletes
that sustained a concussion (184 athletes) underwent clinical assessments
immediately, 3 hours, and 1, 2, 3, 5, 7 and 90 days after injury. The CARE
Consortium enrolled over 40,000 athletes at 30 NCAA Division I, II and III
institutions since 2014. The CARE post-injury concussion assessment involved
follow-up testing of athletes with a concussion (701 football athletes) at <6
hours, 24 to 48 hours, time of asymptomatic, start of RTP protocol, unrestricted
RTP, and 6 months after injury. Both studies collected detailed information on
clinical recovery, management, RTP, and repeat concussion. Overall, compared to
the NCAA Concussion study cohort, the CARE consortium athletes had a longer time
from injury to the asymptomatic time point (~9 days vs ~3 days), symptom
duration (6 days vs 2 days), total time for RTP after concussion (~16 days vs 7
days). The rate of within-season repeat concussion in the CARE Consortium (~4%;
27 athletes out of 701 athletes) was 41% lower than in the NCAA Concussion Study
(~7%; 12 athletes out of 184 athletes). Finally, in the CARE Consortium there
was only one repeat concussion during the first 10 days after an initial injury
 while in contrast 11 of the 12 repeat
concussions in the NCAA Study happened during those first 10 days.

The authors found a major
shift in the clinical management of a sports-related concussion. CARE Consortium
athletes were withheld from play nearly 10 days longer than the original NCAA
cohort. Additionally, CARE athletes reported longer symptom recovery, which
could be attributed to better sign and symptoms assessment or athlete recognition
and knowledge of concussion signs and symptoms. Over 97% of CARE athletes had a
symptom-free waiting period before starting a RTP protocol; in contrast, only ~
60% of NCAA Concussion Study athletes had a symptom-free waiting period. This
combination of lengthier recovery time and a more systematic implementation of
a RTP protocol resulted in a more conservative approach to management compared
with the original NCAA study. Furthermore, the extended recovery period could
be associated with the 41% decline in the within-season repeated concussions. Future
studies should evaluate the impact of concussion education and whether other
medical teams in other sports are adopting a more conservative approach to
concussion management. Currently, medical professionals should be aware of
contemporary concussion recommendations and the evidence supporting these
recommendations to provide proper concussion diagnosis and safe RTP.
Questions for Discussion: How
long do your athletes take to recover following a concussion? Have you noticed
the number of same season repeat concussions declined?
Reviewed by: Jeffrey