Dec. 21, 1999

Concussion Guidelines For Athletes Not Reliable, IU Sports Medicine Specialist Says

INDIANAPOLIS -- An Indiana University School of Medicine sports medicine specialist believes that current guidelines used by many professional and amateur sports teams do not provide adequate safety standards for players.

Douglas B. McKeag, M.D., chairman of the IU Department of Family Medicine and a nationally recognized expert in sports medicine, addressed the controversial issue in a "Contempo" article appearing in the Dec. 21 issue of the Journal of the American Medical Association (JAMA). Contributing to the opinion piece were Michael Collins, Ph.D., and Mark Lovell, Ph.D., of the Division of Neuropsychology at Henry Ford Health System in Detroit.

"My job as a team physician is to make sure that before I return a player to a game he is fully functioning and capable of protecting himself," said Dr. McKeag. "Current guidelines focus more on a player using consciousness as a means of determining his risk, but our research shows that multiple minor incidents can be more damaging."

Dr. McKeag said that mild traumatic brain injury (MTBI), which can be diagnosed through a series of simple tests, is a better yardstick for determining long-term injury from sports-related head injury. MTDI does not imply loss of consciousness, but symptoms do include loss of equilibrium or disorientation. "Multiple incidence of mild traumatic brain injury are more damaging than loss of consciousness," he said.

Dr. McKeag said many teams currently follow concussion guidelines promoted by sports medicine experts or by the American Academy of Neurology that are designed to help the coach, athletic trainer or team physician assign a grade to the concussion based on symptoms. Each grade has a corresponding protocol as to how long the player should be kept out off the playing field. 2 As an example, the Contempo article describes a hockey player who receives an elbow to the face. He experiences confusion without loss of consciousness and passes a brief mental status evaluation. After 30 minutes he reports nausea and dizziness and, at that point, performs poorly on the memory component of the mental status evaluation.

Current American Academy of Neurology guidelines dictate that the athlete experienced a grade 1 concussion. He would be allowed to return to the game within 15 minutes to 20 minutes. The authors contend this action may place the athlete at risk because the effects of his concussion were not initially apparent.

Dr. McKeag said that no research exists to support the specific grades of concussion and return-to-play recommendations. He and Drs. Lovell and Collins published a related article this month in the Clinical Journal of Sport Medicine stating that brief loss of consciousness is not an indicator of how someone will recover following concussion. This finding questions existing guidelines because they base severity of injury on loss of consciousness.

The Contempo article is in response to a Sept. 8 JAMA article in which Drs. McKeag, Collins and Lovell examined long-term effects of concussions on athletes' neuropsychological activity, which includes memory, problem solving, speed of information processing and fine motor speed.

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