Developing guidelines for return to play: Consensus and evidence-based approaches

Abstract

Background: Sports-related concussions are commonplace at all levels of play and across all age groups. The dynamic, evolving nature of this injury coupled with a lack of objective biomarkers creates a challenging management issue for the sports medicine team. Athletes who return to play following a concussion are known to be at higher risk for an additional brain injury, which necessitates a careful, informed return to play (RTP) process.

Aim: The goal of this paper is to outline historical attempts at developing RTP guidelines and trace their evolution over time, culminating in a discussion of the process and outcomes of the most recent consensus statements/guidelines published by the international Concussion In Sport Group (CISG), the American Academy of Neurology (AAN), the National Athletic Trainers’ Association, and the 2013 Team Physician Consensus Statement Update.

Method: An evaluation of the pros and cons of these guidelines is presented along with suggestions for future directions. In addition, the Institute of Medicine recently conducted a comprehensive report outlining the current state of evidence regarding youth concussions, which provides specific recommendations for future research.

Conclusions: The different methodologies utilized in the development of consensus statements have distinct advantages and disadvantages, and both approaches add value to the everyday management of sports concussions. Importantly, the overall approach for management of sports concussion is remarkably similar using either consensus-based or formal evidence-based methods, which adds confidence to the current guidelines and allows practitioners to focus on accepted standards of clinical care. Moving forward, careful study designs need to be utilized to avoid bias in selection of research subjects, collection of data, and interpretation of results. Although useful, clinicians must venture beyond consensus statements to examine reviews of the literature that are published in much greater frequency than consensus statements

• Guidelines
• mild traumatic brain injury
• sports concussion

Declaration of interest

The authors report no conflicts of interest. Dr Echemendia serves as a consultant to the NHL, MLS and US Soccer Federation. He is on the Medical Advisory Board for BrainScope, but does not receive financial compensation. He is also a member of the NCAA Concussion Task Force and a member of the US Lacrosse Sports Science Safety Committee. He is involved in Medicolegal cases, primarily regarding brain injury. He was a member of the scientific organizing committee for CISG-IV. Dr Giza serves as a consultant NHL/NHLPA and NFL NCP. He is a member of the MLS Concussion Program Committee, NCAA Concussion Task Force and California State Athletic Commission. He receives research support from NINDS, NCAA, DOD and the Joseph Drown Foundation. He is involved in 1–2 Medicolegal cases annually. Dr Kutcher is the Director of NBA Concussion Program and serves as a consultant to the NHLPA and NFLPA. He is a member of the NCAA Concussion Task Force and receives research support from ElMindA, Ltd.