Is it Time to Re-think the Zurich Guidelines?
February 27, 2014 5 Comments
Vienna, Prague, Zurich: I’ve often wondered why the Consensus Statements on Concussion are made in central European cities.
The ‘International Consensus Conference on Concussion in Sport’ has taken place successively in Vienna (2001), Prague (2004), Zurich (2008) and again in Zurich (2012). It’s looking like the timing is an Olympiad! And as for venue, I suggest Budapest should start lobbying for 2016…..
But today we won’t be answering the ‘why’ of venue or timing regarding these conferences. We’ll be looking at commentary on the output of the last Zurich meeting: the so-called “Zurich guidelines,” or the Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.
An editorial in our new, March 2014 issue, is entitled: Time to Re-think the Zurich Guidelines? A Critique on the Consensus Statement on Concussion in Sport. Written by Drs. Neil Craton and Oliver Leslie of Legacy Sport Medicine in Winnipeg, Manitoba, Canada, the piece is a provocative deconstruction of the Zurich Guidelines.
The authors have contributed to CJSM in the past. Last year, the pair wrote Concussion: Purely a Brain Injury? and Dr. Craton has contributed several other pieces over the years. The pair are also educators at the University of Manitoba Primary Care Sports Medicine Fellowship. They are busy clinicians as well as writers and teachers, and Dr. Craton includes as his clients the players of the Winnipeg Blue Bombers of the Canadian Football League (CFL).
Concussion, as defined by Zurich, is a subset of traumatic brain injuries. The formal definition, with which many of you will be familiar, is “…a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.”
The editorial authors state that the Zurich guidelines, while providing high sensitivity, lack sufficient specificity. Consequently, they argue that Zurich opens up the possibility that a host of other pathologies (e.g. cervical strain, cervicogenic headaches, benign positional vertigo, etc.) can be construed as concussions. And if understood that way, the potential ‘mis-diagnosis’ can lead to iatrogenic harm: either by initiating a cycle of ineffective treatments, or causing undue worry among patients and families regarding a perceived brain injury. They go so far as to write, “The inclusion criteria for a diagnosis of concussion as articulated by Zurich are absurd (my itals).”
They further note concerns with Zurich regarding: 1) management strategies that are not ‘evidence based’ and 2) rehabilitation goals that are not attainable. They take specific issue with the notion of cognitive rest, stating it is not ‘intuitively obvious’ and is not formally defined. They also criticize the requirement for achieving an ‘asymptomatic’ status prior to beginning a return to play progression, and they cite a study that notes the average uninjured person will not score a zero on the 22-item, Likert Post-concussion Symptom Scale (PCSS). And so, they implicitly argue, what endpoint are we seeking when we are treating a patient with concussion?
It calls to mind the joke I make not infrequently in the room with patients and their families: as far as the PCSS goes, I think the last time I scored all zeros I was probably in my mother’s womb. Headache? Irritability? Drowsiness? Heck yes, if I’m late on my cup of coffee….
The authors make their strongest argument, I think, in what amounts to their peroration: they make an analogy between concussion and another ‘non-specific’ condition, fibromyalgia. “The medical community need only look to a non-specific condition like fibromyalgia,” they argue, “….to see the disability that can be promulgated by non-specific guidelines interfacing with patient hypervigilance, medical pseudoscience, legal wrangling and media scrutiny. We need a better way to protect the health of the athletes we serve.” That’s strong stuff, challenging. What do you think?
I encourage you to read the editorial, freely available, as I write, at our home page, and engage in the conversation that will surely ensue. The piece has already given me a great deal of food for thought. We’ll be talking more about it and related issues in the coming months, and we’re planning a podcast interview with the two authors. You won’t want to miss that!