I think I have had enough time to digest the information in the 4th Consensus Statement; it is enough time for me to give an opinion. WARNING: My opinion may differ than yours and you may even take umbrage with what I say. However I am going to give my honest opinion. To keep it as succinct as possible I will go in bullet form along with the statement itself.
In general I feel that we as the community in the “know” are muddying the waters more when it comes to concussions. I think there are reasons for this; litigation and emotion mainly. I still strongly feel that concussion identification and immediate assessment by trained personnel is non-complex; its simple. Sure others may think it is hard; I think changing the oil in the car is hard and complicated – a mechanic would find that a mundane task.
Secondly, the now undeniable MASSIVE issue with concussions is not the injury itself, rather, the mismanagement of concussion; which includes but not limited to assessment, rest, rehabilitation, return to learn and return to play. The newest consensus statement address some of this for the first time. Now, the paper…
SECTION 1: SPORT CONCUSSION AND MANAGEMENT
- The definition of concussion is more clear for the practitioner.
- Starting to address the psychological aspects of concussions – about time.
- Clearly states if no trained health care provider present that if any signs/symptoms present players must sit out.
- Clearly states that if concussion present, no RTP same day for ANYONE!
- Not really a fan of all the sideline assessments out there. No where does it say its mandatory for any of these; rather they are tools at our disposal to help identify concussions.
- Here is a novel approach people: use your training and ability to be in-tune with the athletes to make a solid clinical judgement. Oh, wait, not every sport team has an athletic trainer available? <–THIS IS THE PROBLEM WITH IDENTIFICATION AND ASSESSMENT.
- The Statement also clearly makes it a point that clinical judgement is the standard of care when it comes to all of this.
- Although currently there is not an objective measure of the injury on the brain they have opened the idea it may be coming.
- Neuropsych testing was a good section, the take-home point here is that baselines are not part of best practices and that they should not be used as a clearance device, except in the case of a trained neuropsych using the information.
- Loved the discussion on “rest”, really thought about it a lot since it came up in Zürich. The term “rest” is so subjective as well, but the Statement made a good effort in trying to convey what most of us already did. Concussions are like orthopedic injuries; we still have a 72 hour window where the inflammation response is active.
- The graduated RTP protocol remains unchanged – which I am most upset with.
- However, the inclusion of (although almost in passing) of return to learn was good to see.
- In the RTP steps all the group had to add was a step between 1 & 2; where it is return to school/work/cognitive activity without symptoms. That was obviously too much to ask, because I asked it be included many times while in Zürich.
- Still no solutions for the 10-15% of “difficult” patients.
- Addressed pharmacological aspects of concussion for the first time, good idea.
- The concussion modifiers are a good point for all of us to consider.
- Special populations or as I call it – “enhanced muddying of the water” – just gives everyone more loopholes to expose and ways to explain down a concussion. A concussion is a concussion is a concussion is a concussion. Now management of said concussion may be different, but the damn injury is the same across the board. Why can we not grasp this?
- Prevention section was refreshing and gaining the most traction early on.
- Yes the way the games are being played is a big contributor to concussions. Remember my quick rant about the sports we play?
- These sports/games were designed for a different human being in the late 1800’s. The size and speed has drastically changed in the athlete, while the game has seen slow and reactive changes that still lag in effectiveness.
- Probably the most overlooked portion of Section I is the “Knowledge Transfer” portion. This is absolutely key, this is exactly why the blog exists.
SECTION 2: STATEMENT ON BACKGROUND TO THE CONSENSUS PROCESS
Perfectly honest, didn’t read much of it, mainly because I was in Zürich and witnessed the process. What you basically need to know here is that the authors of the paper were the ones that came to “consensus” and in some cases they did a tremendous job of getting somewhere without getting anywhere – making us aware; CTE is the example of this good team work. Yet the select group didn’t hear nor heed the concerns of many regarding return to learn (only casual mention).
A lot of the researchers/practitioners in the “consensus” group are very good and nearly void of massive conflict of interest. We must realize that almost everyone there has some “skin in the game”. Unfortunately, most if not all of the “good” guys are non-US-based. I can count on one hand the US based authors I trust on this subject, sorry fellas. This sets up my rant.
In the US the concussion issue is not only overly complex in terms of ID and management, it is overly political; too often the pursuit of money or “fame” gets in the way of solid science. There are “elite” groups of researchers that have the proper connections and pull to get the lion share of grant money and innovation money. And more often than not independent voices/views or decent is met with immediate scoffing from the ivory towers.
Also in the section was the medical-legal concerns, worth the read but also worth nothing, because this does nothing for setting the standard of care we all can be protected by.
SECTION 3: QUESTIONS ADDRESSED
This is worth the investigation people, read what they cited for a background on why certain things were written.