Tougher Rules Advised for Athletes After Concussion

March 18, 2013

Amid mounting evidence about risks of long-term damage to the brain after concussion, the American Academy of Neurology released new guidelines calling for athletes to be removed from play immediately if a concussion is suspected—and kept out until they have been assessed by a medical expert and symptoms are gone.

The guidelines, published Monday online in the journal Neurology, replaces the neurology group's 15-year old system of grading concussions on a severity scale of one to three—which experts say is outmoded. The 1997 guidelines said athletes could return to competition the same day if symptoms like dizziness or headaches cleared within 15 minutes. Athletes and coaches have commonly assumed such mild concussions—often called "getting your bell rung"—are an innocuous injury.

The new guidelines also are more in line with laws in 43 states and the District of Columbia that require youth and high-school athletes to be removed from play and to return only after at least 24 hours and with the permission of a health-care professional. The American Academy of Neurology represents more than 25,000 neurologists and neuroscience professionals.

As many as 3.8 million sports-related traumatic brain injuries—mainly concussions—occur annually in the U.S., and many either go unreported or don't receive immediate medical attention. Emergency-department visits for sports- and recreation-related brain injuries in children and adolescents have risen by 60% over the past decade, according to the Centers for Disease Control and Prevention. Studies indicate concussion risk is greatest in football and rugby followed by hockey and soccer. The risk for young women and girls is greatest in soccer and basketball. Researchers have also identified a gene that predisposes some people to sustaining a concussion.

Michael Collins, director of the sports medicine concussion program at the University of Pittsburgh Medical Center, says the new guidelines are overdue but welcome. "I'm happy to see the AAN is moving beyond a cookbook approach to this injury," says Dr. Collins, who questioned the AAN grading system as too liberal in a 2004 study. "A lot of neurologists have been operating with antiquated information, and this injury is way too variable for that."

The new guidelines codify the mantra "when in doubt, sit it out." And they recognize the importance of individual assessment. In an exhaustive review of all studies published through June 2012, "it has become clear there is no easy way to grade a concussion and no set timeline for a return to play" says Christopher C. Giza, the guidelines' co-lead author and a neurologist at the University of California, Los Angeles.


Athletes in high school and younger who sustain a concussion should be managed more conservatively regarding a return to play, the AAN warns, since they take longer to recover than college-age athletes. Though there isn't enough evidence to support absolute rest, mild activities that don't risk a repeat concussion may be part of management of the injury, the group said.

The guidelines are endorsed by the American Football Coaches Association, the National Association of Emergency Medical Service Physicians and the National Football League Players Association.

An AAN spokeswoman says it tried to seek endorsement from the National Football League but received no response to its outreach.

An NFL spokesman said the request wasn't made to its medical committees and that its own policy adopted in 2009 states that a player who suffers a concussion shouldn't return to play or practice on the same day if he shows any signs or symptoms of a concussion. And a player removed for the duration of a practice or game shouldn't return until cleared by both a team physician and an independent neurological consultant.

The NFL and the player's union, though sometimes at loggerheads over safety issues, are each funding a range of brain-injury research. "Our commitment has been and will be to change the culture of football to better protect players without changing the essence of what makes the game so popular," NFL Commissioner Roger Goodell said at a speech earlier this month at the University of North Carolina. He said there has been a 40% reduction in the number of concussions in each of the past two NFL seasons due to better diagnostic and safety measures.

The AAN advises health professionals to watch for symptoms like headache and fogginess and for younger age and history of concussions—all of which have been linked to a longer recovery time. The first 10 days after the injury appear to be the period of greatest risk for another concussion. The AAN says a combination of tests can be used to help diagnose concussion and predict delayed recovery.

Many schools and sports medicine programs offer tests to athletes before they start contact sports to measure their cognitive function, which can then be compared with the same test administered after a concussion. One, called Impact—or Immediate Post-Concussion Assessment and Cognitive Testing— measures verbal and visual memory, reaction time and impulse control.

Becky Bates, a hairdresser in Newport, N.H., says she hopes the guidelines will help further raise awareness about the risks among both parents and young athletes who don't want to be pulled from play. Her son Benjamin suffered a concussion in the fifth grade. Three years ago, when he was 15, he sustained a head injury playing football; his mother pulled him from play for a week. He was diagnosed as suffering from a migraine rather than a concussion. Even so, she took him to Dartmouth-Hitchcock Medical Center in Lebanon N.H. to take the Impact test so it can be used as a baseline should he sustain another injury. He has since changed schools and is now focusing on baseball.

"I see so many parents and kids try to avoid a diagnosis that might sideline their kids, and there is a lot of ignorance out there still," Ms. Bates says. She and Benjamin agreed to appear on a video about their experience available on Dartmouth-Hitchcock's website.

Write to Laura Landro at

A version of this article appeared March 19, 2013, on page D1 in the U.S. edition of The Wall Street Journal, with the headline: Tougher Rules Advised for Athletes After Concussion.