Update on concussion return to play guidelines: Q&A with a sports medicine physician

female soccer athletes concussion management

The 5th International Conference on Concussion in Sport was recently held in Berlin, Germany. The purpose of the conference was to bring together physicians and researchers from around the globe in order to enhance understanding of sport-related concussions and how they’re treated.

One of the accomplishments of the conference was a shift in the international concussion return to play guidelines. The shift was based on scientific consensus from multiple institutions.

William Meehan, MD, of Boston Children’s Division of Sports Medicine explains the changes and how Boston Children’s helped make these advancements possible.

How have the international concussion return to play guidelines changed?

The most significant change was in the management of concussions. Previous guidelines have recommended rest in two forms: physical, which for most people is avoidance of exercise, and cognitive, which means not engaging in mentally strenuous activities.

Past guidelines recommended both physical and cognitive rest until the patient is completely symptom-free. But there has been a substantial amount of research over the last four to six years showing that by engaging in some physical and cognitive activity, symptoms go away faster.

The biggest change is that now we might prescribe 24-48 hours of rest, but then it’s recommended the patient starts getting back into some level of safe activities, even if they are still having symptoms of a concussion.

What research is being done at Boston Children’s on the effects of sports-related concussions?

At the conference, research from Boston Children’s was cited as much as any other institution when all data was presented. I was quite proud of our investigators. Specifically, six studies by Boston Children’s researchers were referenced during the consensus discussions and presentations that led to the changes in the recommendations.

As far as the biggest change — which is the amount of recommended rest — we have published several articles showing there is little to no value in complete cognitive and physical rest. The first article was published a long time ago, when cognitive rest was becoming a new concept. Some of the doctors at Boston Children’s were recommending cognitive rest to athletes, others were not since it wasn’t evidence-based yet. We went back and looked at the charts of several hundred athletes, and separated them into two groups: those who were recommended cognitive rest and those who weren’t. We found that the recommendation for cognitive rest was not associated with faster recovery.

Later, we did a second study where we looked at the amount of cognitive activity athletes did during their recovery. It turned out, for athletes who engaged in the highest amount of cognitive activity, their recovery was prolonged. But patients who engaged in minimal/mild cognitive activity or moderate cognitive activity got better around the same time. Ultimately, we concluded that maybe you can’t do it all, but complete cognitive rest is unnecessary. People just largely ignored concussions in the past, but now all of a sudden there has been this major effort put into research.”

Lastly, we asked concussion patients in our clinic if they have been exercising. All had been told not to exercise, but some did anyway. Rather than admonish them, we surveyed their activity. It turns out, the ones that had been exercising improved faster than the ones who weren’t, particularly the adolescents (ages 14-18). That research — along with studies from other groups — led directly to the change in recommendations we have now. In fact, long before the international guidelines were changed, we had already changed our practice to reflect the findings.

How have the research efforts behind sport-related concussions grown in recent years?

The research has grown tremendously. One of my colleagues posted a paper a few years back that showed all of the research on sport-related concussions published before 2007. It was less than the research that had been published between 2007 and 2012. People just largely ignored concussions in the past, but now all of a sudden there has been this major effort put into research.

We’ve learned a ton, and as a result we manage athletes differently and in a way that decreases their risk of having long-term problems from concussions. The one negative thing that has happened is the discussion has moved itself from the medical media and into the lay media and public discussion. The amount of misinformation that gets put out there in newspaper reports and related media outlets is incredible. It’s having adverse effects on what people do and adverse effects on patients who read it.

There have been several editorials recently from doctors saying that we need to stop talking to the media and keep it in the medical literature until we work it out, and I think that’s right. There are people who are convinced that they have diagnoses and the associated symptoms that they are highly unlikely to have. Since they are convinced they have these diagnoses, for which there are no available treatments, it can be hard to get them to accept treatments for the conditions that are likely explaining their symptoms. Some patients aren’t willing to consider treatments that would likely benefit them.

It has nothing to do with the medical literature, but it has everything to do with how it’s talked about in the media. It’s just the wrong way to do it. In the medical community, we’re trying to improve our understanding of concussions in order to provide better care for our patients — and that’s tough to do with a lot of misinformation out there.

Learn more about the Sports Medicine Division at Boston Children’s Hospital.

Dr. William Meehan

About our expert:

William Meehan, MD, is a sports medicine physician at Boston Children’s and the Director of The Micheli Center for Sports Injury Prevention. He is also an assistant professor of Pediatrics and Orthopedics at Harvard Medical School, as well as the associate director of the Football Players Health Study at Harvard University.