New Concussion Guidelines Emphasize Active Recovery

Times have changed for concussion diagnosis and treatment. No longer does evaluation typically involve head imaging or grading the injury's severity on a scale of 1 to 3. And gone are the days when doctors recommended complete rest for recovery. In 2023, new guidelines for identifying and treating sports-related concussions were published suggesting that, among other things, athletes return to some form of physical activity within a few days of the injury.

At the beginning of the fall sports season, we checked in with Dr. Nicolas Hatamiya, a primary care sports medicine doctor who sees children and adults through the sports concussion programs at UCSF Benioff Children's Hospitals and UCSF Health. Hatamiya, who is also team doctor for the Oakland Roots professional soccer team, shared the latest on concussions, including the updated guidelines.

What are the symptoms of a concussion?

There are a wide range of symptoms that people can experience, including headaches, confusion, nausea, fatigue, balance problems, emotionality and changes in sleep.

With increasing awareness of concussions, has there been a decline in injuries or severity?

Data from our larger injury surveillance systems suggest there may be increased numbers of concussions being diagnosed. I suspect this is in part due to increased awareness among coaches, parents, patients and health care providers.

What are the new guidelines and what is new in them?

In 2023, new recommendations and guidelines from an international group of experts were published in the British Journal of Sports Medicine. Some of the biggest changes relate to return-to-learn and return-to-sport guidelines. They emphasize active recovery. The changes were based on new evidence, including an important 2019 study that showed introducing mild aerobic activity can reduce recovery time from sports-related concussions.

How do you diagnose a concussion?

We have a lot of tools that we use, but there is no gold standard. In a clinical evaluation – which should happen within 72 hours of an injury – we ask patients to identify and rate their symptoms, have them perform a series of memory and balance tasks, and do a thorough neurologic exam.

What would you do differently, if anything, with an athlete who has already had a couple of concussions?

In general, I think I would emphasize that every concussion is different, so just because a patient felt a certain way with their first concussion doesn't mean the second is going to be the same. A lot of times, people ask, How many is too many? But there isn't a clearly defined number of concussions that's safe or a clearly defined number that becomes more dangerous. It's about shared decision-making and trying to figure out what's best for the athlete.

What are the most common misconceptions about concussions?

Some people still believe you need to lose consciousness to be diagnosed with a concussion, which we know is not true. You don't even have to be hit specifically in the head to be diagnosed with a concussion. It can occur from a blow to the body that transmits a force up to the brain.

And some doctors, unfortunately, still tell their patients to just stay quiet in their rooms until they don't have symptoms. But we know now that promoting early contact-free aerobic activity after the first 48 hours can help facilitate concussion recovery.

Do you know whether any of the preventive measures we've heard about – such as special helmets or modified rules in youth soccer and football – are working?

This is an area that we're actively researching. We know that some rule changes, such as disallowing body checking in adolescent ice hockey, led to big reductions in concussions. Limiting contact practices in American football has also reduced concussions. It makes sense: less exposure, less risk. I should say concussions occur in every sport – football, soccer, lacrosse, ice hockey, rugby – even track, if the athlete falls on one of the hurdles. These freak accidents do happen.

Should athletes and parents worry about concussions when making decisions about sports participation?

All concussions are potentially serious. But kids benefit socially and healthwise from being involved with sports. And if a concussion is diagnosed and treated correctly, most patients recover within a matter of days to weeks. And even if a concussion is diagnosed late or is mistreated at first, most patients who begin appropriate treatment can still fully recover.