E-letter: More science please

By Justin A Paoloni

I read with interest the Consensus Statement on Concussion, and believe this worthwhile in furthering scientific knowledge on concussion in sport. However, I have concerns about definitive comments in the consensus statement, given the lack of supporting scientific evidence. Whilst this consensus document is only “a guide and is of a general nature consistent with the reasonable practice of a healthcare professional”, it is also “reflects the current state of knowledge”. This comment does not accurately represent the documents’ contents with definitive statements not evidenced based.

I agree with the preamble; “management and return to play decisions remain in the realm of clinical judgement on an individualized basis”, as scant high level evidence is available on concussion management. However, Section 2.2 states that “a player with diagnosed concussion should not be allowed to return to play on the day of injury. Occasionally, in adult athletes, there may be a return to play on the same day of injury (see Section 4.2)”, which follows with “adult athletes, in some settings, where there are team physicians experienced in concussion management and sufficient resources…return to play may be more rapid.” These statements have multiple qualifiers, but do not represent the management of concussion in sport. More than “occasionally” do athletes return to play on the same day after medical assessment and symptom resolution, and this appears safe and effective. The return to play decision does not require the “sufficient resources” mentioned, but does require a physician experienced in concussion management. Certainly, there are no scientific studies, and no comparison studies, with high enough level of evidence to definitively support either approach.

Section 11 states that “the consensus statement is intended to serve as the scientific record of the conference”. Thus, these definitive statements on concussion management, from an expert panel, require supporting scientific evidence and appropriate referencing, as for any scientific paper. To make these statements without quoting relevant high level evidence is not scientific. There are potential legal ramifications for medical practitioners who do not follow these concussion management guidelines.

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