Identifying concussion: when guidelines collide with real-world implementation-is a formal medical diagnosis necessary in every case once a proper protocol is implemented?

MAIN TEXT Several countries, such as Canada, are in the process of defining strategies to address the public health problem of sport-related concussions. One of the challenges is to develop strategies that can apply at the earlier levels where the timely availability of qualified healthcare resources is limited. Here, I respectfully challenge the notion that every athlete with suspected concussion should have a medical consultation to confirm the diagnosis. Specifically, I question the added value of the systematic requirement for a medical diagnosis in a sport or school-based environment, when a suspected case of concussion without any ‘red flag’ (as per the concussion recognition tool) is identified and a proper concussion management protocol is initiated. The Zurich consensus states that, following the identification of a suspected case of concussion, ‘The final determination regarding concussion diagnosis and/or fitness to play is a medical decision based on clinical judgement’. Also, the concussion recognition tool recommends that: ‘... in all cases of suspected concussion, the player is referred to a medical professional for diagnosis and guidance...’. However, the American Academy of Neurology position statement on concussion only requires that the injured athlete does not ‘return to play until... assessed by an experienced licensed healthcare provider with training both in the diagnosis and management of concussion...’.