Refer to Medical Policy Y-21, Cognitive Rehabilitation for additional information.

Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology

• OBJECTIVE:  To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae?
• RESULTS:  Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. There is insufficient evidence to support conclusions about the use of neuropsychological testing in identifying concussion in preadolescent age groups. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Consensus statement on concussion in sport—the 5^th international conference on concussion in sport held in Berlin, October 2016

• The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgment.
• This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps.
• At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of SRC in the sporting environment. Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological (NP) test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the SCAT5, which incorporates the Maddocks' questions and the Standardised Assessment of Concussion (SAC). It is worth noting that standard orientation questions (eg, time, place, person) are unreliable in the sporting situation when compared with memory assessment. It is recognized, however, that abbreviated testing paradigms are designed for rapid SRC screening on the sidelines and are not meant to replace a comprehensive neurological evaluation; nor should they be used as a standalone tool for the ongoing management of SRC.
• The SCAT5 currently represents the most well-established and rigorously developed instrument available for sideline assessment. There is published support for using the SCAT and Child SCAT in the evaluation of SRC. The SCAT is useful immediately after injury in differentiating concussed from non-concussed athletes, but its utility appears to decrease significantly 3–5 days after injury. The symptom checklist, however, does demonstrate clinical utility in tracking recovery. Baseline testing may be useful, but is not necessary for interpreting post-injury scores. If used, clinicians must strive to replicate baseline testing conditions. Additional domains that may add to the clinical utility of the SCAT tool include clinical reaction time, gait/balance assessment, video-observable signs and oculomotor screening.
• Baseline or pre-season NP testing was considered by the panel and was not felt to be required as a mandatory aspect of every assessment; however, it may be helpful or add useful information to the overall interpretation of these tests. It also provides an additional educative opportunity for the healthcare provider to discuss the significance of this injury with the athlete.
• Post-injury NP testing is not required for all athletes. However, when this is considered necessary, the assessment should optimally be performed by a trained and accredited neuropsychologist. Although neuropsychologists are in the best position to interpret NP tests by virtue of their background and training, the ultimate return-to-play decision should remain a medical one in which a multidisciplinary approach, when possible, has been taken. In the absence of NP and other testing, a more conservative return-to-play approach may be appropriate.