Gone are the days when a coach could do an on-the-spot diagnosis of a teenager who had taken a ball or elbow to the head, and then send the player back to the field in a matter of minutes.
In a new report, aimed at members of the American Academy of Pediatrics, two researchers at Washington University's medical school are advising pediatricians to discard many outdated procedures, and to take a more cautious approach to the treatment of concussion, which is a disturbance in brain function caused by direct or indirect force to the head.
"Even though they may seem symptom-free, their brain may not be recovered," says one of those researchers, Dr. Mark Halstead, an assistant professor in orthopedics and pediatrics at the university, who in the past has trained as a sports physician and worked with teen football players.
Published in the journal Pediatrics, the report draws on the most up-to-date research on diagnosing and treating sports-related concussions in children.
Concussion results in a wide range of physical, cognitive and emotional symptoms. Based on North American estimates, about 425,000 Canadian children experience recreation- and sports-related concussions a year. But concussion is tricky to diagnose because the signs can be easily overlooked. Symptoms include headache, nausea, feeling "in a fog," difficulty concentrating and being more emotional or anxious.
"It is an area that for a long time people just down-played," says Dr. Halstead, who is also the team physician for the St. Louis Rams, on the phone from Providence, R.I., where the Rams were playing the Patriots. "You got dinged, you got your bell rung. It was considered part of the game."
A new study appearing in the same issue of Pediatrics found that of about 502,000 U.S. emergency-department visits by eight-to-19 year-olds for concussion, roughly half were sports-related. Among eight-to-13-year-olds, sports-related concussions accounted for close to 60 per cent of all their concussions - and were due mostly to football.
The new AAP guidelines are largely based on policies agreed upon by medical experts at a major symposium on concussion in sport in Zurich in 2008. They include a diagnostic tool called the Sport Concussion Assessment Tool 2 (SCAT2), an update of a 2005 version.
In one of the recommendations, the experts urge a more detailed definition of concussion to combat common myths.
A concussion can be caused not just by a blow to the head, but also by a body blow that causes the head to snap the same way. Loss of consciousness is not common, and neuro-imaging, such as MRI or CT, will show no abnormalities.
The report also reminds pediatricians that some diagnostic tools are out of date, including a once widely used three-tier grading system.
Another system dividing concussions into "simple" and "complex" categories is deemed to be arbitrary.
Dr. Halstead says he still sees doctors using the old tools and determining that an athlete can return to play before he's ready. Research shows that a first concussion increases the likelihood of a second - and a second injury while a child is still symptomatic can be fatal.
Another major recommendation is the notion of "brain rest" - not just physical rest, but a break from TV, video games and school.
Elaine Keuner, a Niagara-area mother of 13-year-old twin boys, has been through a concussion with each one. She has become an advocate for hockey safety with the non-profit ThinkFirst Canada.
"The word has gotten out there because of the NHL players who have come forward," she says. "There's still a lot of work to be done and unfortunately a lot of hockey and sports associations have got to take it upon themselves to educate. And parents have got to look into it."
Family doctors are especially important to reach because they are the ones often faced with athletes asking for a doctor's note to get back on the field or the ice, says Mark Aubry, the Ottawa-based chief medical officer of the International Ice Hockey Federation. "It's difficult for them to read everything and know everything," says Dr. Aubry, who was part of the Zurich symposium and discussed the issue at last week's World Hockey Summit in Toronto.