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Academy of Neurology Releases Updated Sports-Concussion Guideline

Student-athletes' recovery from a concussion should be assessed on a case-by-case basis, recommends the new sports-related concussion guideline from the American Academy of Neurology, published online Monday in the journal Neurology.

The new evidence-based guideline replaces the academy's previous version, released in 1997, which recommended grading concussions on a scale of 1, 2, or 3.

"We've moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return-to-play be assessed in each athlete individually," said co-lead author Dr. Christopher C. Giza, with the David Geffen School of Medicine and Mattel Children's Hospital at UCLA, in a statement. "There is no set timeline for safe return-to-play."

According to the 1997 guideline, grade 1 concussions were those that resulted in no loss of consciousness and a resolution of symptoms within 15 minutes, while grade 2 concussions featured symptoms that lasted longer than 15 minutes but still resulted in no loss of consciousness. A concussion was considered grade 3 if the athlete lost consciousness at all.

That scale ended up outliving its usefulness, said Dr. Geoffrey Manley, one of the co-authors of the new guideline and the chief of neurosurgery at San Francisco General Hospital, to USA Today.

"We've seen people that have not lost consciousness that can actually have a worse outcome than those that have lost consciousness," Manley said. "So there's really no data to really support this idea of these different grades."

The new guideline also recommends that any student-athlete suspected of a concussion should be removed immediately and prevented from returning to play until he or she receives clearance from a licensed health-care provider. The health-care provider should ensure that the student-athlete's concussion symptoms have fully resolved before making the return-to-play (RTP) decision, the guideline suggests.

Due to physiological differences between adults and adolescents, the academy suggests being more cautious with younger athletes who have sustained concussions.

"Individuals supervising athletes of high school age or younger with diagnosed concussion should manage them more conservatively regarding RTP than they manage older athletes," the academy said in the new guideline.

The removal-from-play recommendation is a cornerstone of nearly every state's states' youth concussion legislation, along with the requirement that any student-athlete removed due to a possible concussion must obtain medical clearance from a health-care provider before returning to play.

In terms of concussion evaluation, the guideline suggests that neuropsychological testing is likely "useful in identifying the presence of concussion." However, the academy stopped short of recommending neuropsychological testing for pre-adolescents due to insufficient evidence.

That echoes what appears in the new consensus statement on concussion in sport released last week, which also cited insufficient evidence as a reason not to recommend the widespread use of neuropsychological testing. The consensus statement said that such testing should never be used in isolation when making a return-to-play decision.

To create the new guideline, a multidisciplinary panel of experts reviewed a host of concussion-related research released since 1997. Among the studies evaluated, the risk of concussion appeared to be highest for boys in American football and rugby, while soccer and basketball carried the greatest risk of concussions for girls and young women.

High school male student-athletes sustained 1.55 concussions per 1,000 football games; 0.59 concussions per 1,000 soccer games; and only 0.11 concussions per 1,000 basketball games. Meanwhile, high school females sustained 0.97 concussions per 1,000 soccer games and 0.60 concussions per 1,000 basketball games.

Baseball, softball, volleyball, and gymnastics appeared to be associated with the lowest risk of concussion, according to the academy.

In conjunction with the release of the new guideline, the academy also released a new app called "Concussion QuickCheck" to help with sideline concussion evaluations. It's available for the iPad, iPhone, Android, and other mobile devices. For more concussion-related resources, check out the academy's sports-concussion toolkit.

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