CONSENSUS STATEMENT          Consensus Statement on Concussion in Sport          rd       3 International Conference on Co...
McCrory et al                                                                Clin J Sport Med  Volume 19, Number 3, May 20...
Clin J Sport Med  Volume 19, Number 3, May 2009                                               Consensus Statement on Concu...
McCrory et al                                                                          Clin J Sport Med  Volume 19, Number...
Clin J Sport Med  Volume 19, Number 3, May 2009                                                    Consensus Statement on ...
McCrory et al                                                                Clin J Sport Med  Volume 19, Number 3, May 20...
Clin J Sport Med  Volume 19, Number 3, May 2009                                                    Consensus Statement on ...
McCrory et al                                                                              Clin J Sport Med  Volume 19, Nu...
Clin J Sport Med  Volume 19, Number 3, May 2009                                                                   Consensu...
McCrory et al                                                                                 Clin J Sport Med  Volume 19,...
Clin J Sport Med  Volume 19, Number 3, May 2009                                                                 Consensus ...
Sport Concussion Assessment Tool 2 (SCAT2)
Sport Concussion Assessment Tool 2 (SCAT2)
Sport Concussion Assessment Tool 2 (SCAT2)
Sport Concussion Assessment Tool 2 (SCAT2)
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Consensus statement on concussion in sport


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Consensus statement on concussion in sport

  1. 1. CONSENSUS STATEMENT Consensus Statement on Concussion in Sport rd 3 International Conference on Concussion in Sport Held in Zurich, November 2008 Paul McCrory, MBBS, PhD,* Willem Meeuwisse, MD, PhD,† Karen Johnston, MD, PhD,‡ Jiri Dvorak, MD,§ Mark Aubry, MD,k Mick Molloy, MB,¶ and Robert Cantu, MA, MD#(Clin J Sport Med 2009;19:185–200) encouraged to copy and distribute freely the Zurich Consensus document and/or the Sport Concussion Assessment Tool (SCAT2) card, and neither is subject to any copyrightPreamble restriction. The authors request, however, that the document This paper is a revision and update of the recommen- and/or the SCAT2 card be distributed in their full and completedations developed following the 1st (Vienna) and 2nd (Prague) format.International Symposia on Concussion in Sport.1,2 The Zurich The following focus questions formed the foundation forConsensus statement is designed to build on the principles the Zurich concussion consensus statement:outlined in the original Vienna and Prague documents and todevelop further conceptual understanding of this problem Acute Simple Concussionusing a formal consensus-based approach. A detailed de- Which symptom scale and which sideline assessment tool isscription of the consensus process is outlined at the end of this best for diagnosis and/or follow up?document under the ‘‘Background’’ section (see Section 11). How extensive should the cognitive assessment be in eliteThis document is developed for use by physicians, therapists, athletes?certified athletic trainers, health professionals, coaches and How extensive should clinical and neuropsychological (NP)other people involved in the care of injured athletes, whether at testing be at non-elite level?the recreational, elite or professional level. Who should do/interpret the cognitive assessment? While agreement exists pertaining to principal messages Is there a gender difference in concussion incidence andconveyed within this document, the authors acknowledge that outcomes?the science of concussion is evolving and therefore manage-ment and return to play decisions remain in the realm ofclinical judgment on an individualized basis. Readers are Return to Play (RTP) Issues Is provocative exercise testing useful in guiding RTP? What is the best RTP strategy for elite athletes? What is the best RTP strategy for non-elite athletes?Submitted for publication January 14, 2009; accepted March 11, 2009. From the *Centre for Health, Exercise Sports Medicine, University of Is protective equipment (eg, mouthguards and helmets) Melbourne, Parkville, Australia; †Sport Medicine Centre, Faculty of useful in reducing concussion incidence and/or severity? Kinesiology, and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; ‡Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario, Complex Concussion and Long-term Issues Canada; §FIFA Medical Assessment and Research Center (F-MARC) and Is the Simple versus Complex classification a valid and Schulthess Clinic, Zurich, Switzerland; kInternational Ice Hockey useful differentiation? Federation and Hockey Canada, and Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada; {International Rugby Board, Dublin, Ireland; Are there specific patient populations at risk of long-term and #Department of Neurosurgery and Department of Sport Medicine, problems? Emerson Hospital, Concord, Massachusetts. Is there a role for additional tests (eg, structural and/orConsensus panelists (listed in alphabetical order): In addition to the authors functional MR Imaging, balance testing, biomarkers)? above, the consensus panelists were Steve Broglio, Gavin Davis, Randall Should athletes with persistent symptoms be screened for Dick, Ruben Echemendia, Gerry Gioia, Kevin Guskiewicz, Stan Herring, Grant Iverson, Jim Kelly, Jamie Kissick, Michael Makdissi, Michael depression/anxiety? McCrea, Alain Ptito, Laura Purcell, and Margot Putukian. Also invited but not in attendance: Roald Bahr, Lars Engebretsen, Peter Hamlyn, Barry Jordan, and Patrick Schamasch. Paediatric ConcussionCompeting Interests: The authors have no competing interests to declare. Which symptoms scale is appropriate for this age group?Reprints: not available. Which tests are useful and how often should baseline testingCorrespondence: Assoc. Prof. Paul McCrory, MBBS, PhD, Centre for Health, Exercise Sports Medicine, University of Melbourne, Parkville, be performed in this age group? Australia 3010 (e-mail: What is the most appropriate RTP guideline for elite andCopyright Ó 2009 by Lippincott Williams Wilkins non-elite child and adolescent athletes?Clin J Sport Med Volume 19, Number 3, May 2009 | 185
  2. 2. McCrory et al Clin J Sport Med Volume 19, Number 3, May 2009Future Directions 2. CONCUSSION EVALUATION What is the best method of knowledge transfer and education? 2.1 Symptoms and Signs of Acute Concussion Is there evidence that new and novel injury prevention The panel agreed that the diagnosis of acute concussion strategies work (eg, changes to rules of the game, fair play usually involves the assessment of a range of domains strategies, etc.)? including clinical symptoms, physical signs, behavior, The Zurich document additionally examines the balance, sleep and cognition. Furthermore, a detailed concus-management issues raised in the previous Prague and Vienna sion history is an important part of the evaluation both in thedocuments and applies the consensus questions to these areas. injured athlete and when conducting a pre-participation examination. The detailed clinical assessment of concussion is outlined in the SCAT2 form, which is an appendix to this SPECIFIC RESEARCH QUESTIONS AND document. CONSENSUS DISCUSSION The suspected diagnosis of concussion can include one or more of the following clinical domains: 1. CONCUSSION (a) Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability)1.1 Definition of Concussion (b) Physical signs (eg, loss of consciousness, amnesia) Panel discussion regarding the definition of concussion (c) Behavioural changes (eg, irritablity)and its separation from mild traumatic brain injury (mTBI) (d) Cognitive impairment (eg, slowed reaction times)was held. Although there was acknowledgement that the (e) Sleep disturbance (eg, drowsiness)terms refer to different injury constructs and should not be If any one or more of these components is present, aused interchangeably, it was not felt that the panel would concussion should be suspected and the appropriate manage-define mTBI for the purpose of this document. There was ment strategy instituted.unanimous agreement, however, that concussion is definedas follows: Concussion is defined as a complex pathophysiological 2.2 On-field or Sideline Evaluation ofprocess affecting the brain, induced by traumatic biomechan- Acute Concussionical forces. Several common features that incorporate clinical, When a player shows ANY features of a concussion:pathologic and biomechanical injury constructs that may be (a) The player should be medically evaluated onsite usingutilized in defining the nature of a concussive head injury standard emergency management principles, and particularinclude: attention should be given to excluding a cervical spine1. Concussion may be caused either by a direct blow to the injury. head, face, neck or elsewhere on the body with an (b) The appropriate disposition of the player must be ÔÔimpulsiveÕÕ force transmitted to the head. determined by the treating healthcare provider in a timely2. Concussion typically results in the rapid onset of short- manner. If no healthcare provider is available, the player lived impairment of neurologic function that resolves should be safely removed from practice or play and urgent spontaneously. referral to a physician arranged.3. Concussion may result in neuropathological changes, but (c) Once the first aid issues are addressed, then an assessment the acute clinical symptoms largely reflect a functional of the concussive injury should be made using the SCAT2 disturbance rather than a structural injury. or other similar tool.4. Concussion results in a graded set of clinical symptoms that (d) The player should not be left alone following the injury, may or may not involve loss of consciousness. Resolution and serial monitoring for deterioration is essential over the of the clinical and cognitive symptoms typically follows initial few hours following injury. a sequential course; however, it is important to note that, in (e) A player with diagnosed concussion should not be allowed a small percentage of cases, post-concussive symptoms may to return to play on the day of injury. Occasionally, in adult be prolonged. athletes, there may be return to play on the same day as the5. No abnormality on standard structural neuroimaging injury. (See section 4.2.) studies is seen in concussion. It was unanimously agreed that sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all1.2 Classification of Concussion injured athletes. In some sports this may require rule change There was unanimous agreement to abandon the Simple to allow an off-field medical assessment to occur withoutvs. Complex terminology that had been proposed in the Prague affecting the flow of the game or unduly penalizing the injuredagreement statement, as the panel felt that the terminology player’s team.itself did not fully describe the entities. However, the panel Sideline evaluation of cognitive function is an essentialunanimously retained the concept that the majority (80%- component in the assessment of this injury. Brief neuro-90%) of concussions resolve in a short (7-10 day) period, psychological test batteries that assess attention and memoryalthough the recovery time frame may be longer in children function have been shown to be practical and effective. Suchand adolescents.2 tests include the Maddocks questions3,4 and the Standardized186 | q 2009 Lippincott Williams Wilkins
  3. 3. Clin J Sport Med Volume 19, Number 3, May 2009 Consensus Statement on ConcussionAssessment of Concussion (SAC).5–7 It is worth noting that abnormalities that may be incidentally discovered is notstandard orientation questions (eg, time, place, person) have established at the present time.been shown to be unreliable in the sporting situation when Other imaging modalities such as fMRI demonstratecompared with memory assessment.4,8 It is recognized, activation patterns that correlate with symptom severity andhowever, that abbreviated testing paradigms are designed for recovery in concussion.9–13 Whilst not part of routine assess-rapid concussion screening on the sidelines and are not meant ment at the present time, they nevertheless provide additionalto replace comprehensive neuropsychological testing which is insight to pathophysiological mechanisms. Alternative imag-sensitive to detect subtle deficits that may exist beyond the ing technologies (eg, positron emission tomography, diffusionacute episode nor should they be used as a stand-alone tool for tensor imaging, magnetic resonance spectroscopy, functionalthe ongoing management of sports concussions. connectivity), while demonstrating some compelling findings, It should also be recognized that the appearance of are still at early stages of development and cannot be recom-symptoms might be delayed several hours following a con- mended other than in a research setting.cussive episode.2.3 Evaluation in Emergency Room or Office by 3.2 Objective Balance AssessmentMedical Personnel Published studies using both sophisticated force plate An athlete with concussion may be evaluated in the technology, as well as those using less sophisticated clinicalemergency room or doctor’s office as a point of first contact balance tests (eg, Balance Error Scoring System (BESS)),following injury or may have been referred from another care have identified postural stability deficits lasting approximatelyprovider. In addition to the points outlined above, the key 72 hours following sport-related concussion. It appears thatfeatures of this exam should encompass: postural stability testing provides a useful tool for objectively assessing the motor domain of neurologic functioning and(a) A medical assessment including a comprehensive history should be considered a reliable and valid addition to the and detailed neurological examination including a thor- assessment of athletes suffering from concussion, particularly ough assessment of mental status, cognitive functioning where symptoms or signs indicate a balance component.14–20 and gait and balance.(b) A determination of the clinical status of the patient including whether there has been improvement or 3.3 Neuropsychological Assessment deterioration since the time of injury. This may involve The application of neuropsychological (NP) testing in seeking additional information from parents, coaches, concussion has been shown to be of clinical value and teammates and eyewitness to the injury. continues to contribute significant information in concussion(c) A determination of the need for emergent neuroimaging in evaluation.21–26 Although in most case cognitive recovery order to exclude a more severe brain injury involving largely overlaps with the time course of symptom recovery, it a structural abnormality. has been demonstrated that cognitive recovery may occasion- In large part, these points above are included in the ally precede or more commonly follow clinical symptomSCAT2 assessment, which forms part of the Zurich consensus resolution suggesting that the assessment of cognitive functionstatement. should be an important component in any return to play protocol.27,28 It must be emphasized, however, that NP assess- ment should not be the sole basis of management decisions; 3. CONCUSSION INVESTIGATIONS rather, it should be seen as an aid to the clinical decision- A range of additional investigations may be utilized making process in conjunction with a range of clinicalto assist in the diagnosis and/or exclusion of injury. These domains and investigational results.include: Neuropsychologists are in the best position to interpret NP tests by virtue of their background and training. However,3.1 Neuroimaging there may be situations where neuropsychologists are not It was recognized by the panelists that conventional available and other medical professionals may perform orstructural neuroimaging is normal in concussive injury. Given interpret NP screening tests. The ultimate return to playthat caveat, the following suggestions are made: Brain CT (or, decision should remain a medical one in which a multidisci-where available, MR brain scan) contributes little to concussion plinary approach, when possible, has been taken. In theevaluation but should be employed whenever suspicion of an absence of NP and other (eg, formal balance assessment)intra-cerebral structural lesion exists. Examples of such testing, a more conservative return to play approach may besituations may include prolonged disturbance of conscious appropriate.state, focal neurological deficit or worsening symptoms. In the majority of cases, NP testing will be used to assist Newer structural MRI modalities including gradient return to play decisions and will not be done until the patientecho, perfusion and diffusion imaging have greater sensitivity is symptom free.29,30 There may be situations (eg, child andfor structural abnormalities. However, the lack of published adolescent athletes) where testing may be performed earlystudies, as well as absent pre-injury neuroimaging data, limits whilst the patient is still symptomatic to assist in determiningthe usefulness of this approach in clinical management at the management. This will normally be best determined inpresent time. In addition, the predictive value of various MR consultation with a trained neuropsychologist.31,32q 2009 Lippincott Williams Wilkins | 187
  4. 4. McCrory et al Clin J Sport Med Volume 19, Number 3, May 20093.4 Genetic Testing recovery, while symptomatically following an injury, it is The significance of Apolipoprotein (Apo) E4, ApoE important to emphasize to the athlete that physical ANDpromotor gene, Tau polymerase and other genetic markers in cognitive rest is required. Activities that require concentrationthe management of sports concussion risk or injury outcome is and attention (eg, scholastic work, videogames, text messaging,unclear at this time.33,34 Evidence from human and animal etc.) may exacerbate symptoms and possibly delay recovery. Instudies in more severe traumatic brain injury demonstrates such cases, apart from limiting relevant physical and cognitiveinduction of a variety of genetic and cytokine factors such as: activities (and other risk-taking opportunities for re-injury),insulin-like growth factor-1 (IGF-1), IGF binding protein-2, while symptomatic, no further intervention is required duringFibroblast growth factor, Cu-Zn superoxide dismutase, the period of recovery, and the athlete typically resumes sportsuperoxide dismutase-1 (SOD-1), nerve growth factor, glial without further problem.fibrillary acidic protein (GFAP) and S-100. Whether suchfactors are affected in sporting concussion is not known at 4.1 Graduated Return to Play Protocolthis stage.35–42 Return to play protocol following a concussion follows a stepwise process as outlined in Table 1.3.5 Experimental Concussion With this stepwise progression, the athlete shouldAssessment Modalities continue to proceed to the next level if asymptomatic at the Different electrophysiological recording techniques (eg, current level. Generally, each step should take 24 hours so thatevoked response potential (ERP), cortical magnetic stimula- an athlete would take approximately one week to proceedtion and electroencephalography) have demonstrated repro- through the full rehabilitation protocol once they areducible abnormalities in the post concussive state; however, asymptomatic at rest and with provocative exercise. If anynot all studies reliably differentiated concussed athletes from post-concussion symptoms occur while in the stepwisecontrols.43–49 The clinical significance of these changes program, then the patient should drop back to the previousremains to be established. asymptomatic level and try to progress again after a further In addition, biochemical serum and cerebral spinal fluid 24-hour period of rest has passed.markers of brain injury (including S-100, neuron specificenolase (NSE), myelin basic protein (MBP), GFAP, tau, etc.) 4.2 Same Day RTPhave been proposed as means by which cellular damage may With adult athletes, in some settings, where there arebe detected if present.50–56 There is currently insufficient team physicians experienced in concussion management andevidence, however, to justify the routine use of these sufficient resources (eg, access to neuropsychologists, con-biomarkers clinically. sultants, neuroimaging, etc.), as well as access to immediate (ie, sideline) neuro-cognitive assessment, return to play management may be more rapid. The RTP strategy must still 4. CONCUSSION MANAGEMENT follow the same basic management principles, namely, full The cornerstone of concussion management is physical clinical and cognitive recovery before consideration of returnand cognitive rest until symptoms resolve and then a graded to play. This approach is supported by published guidelines,program of exertion prior to medical clearance and return to such as the American Academy of Neurology, US Teamplay. The recovery and outcome of this injury may be modified Physician Consensus Statement, and US National Athleticby a number of factors that may require more sophisticated Trainers’ Association Position Statement.58–60 This issue wasmanagement strategies. These are outlined in the section on extensively discussed by the consensus panelists, and it wasmodifiers below. acknowledged that there is evidence that some professional As described above, the majority of injuries will recover American football players are able to RTP more quickly, withspontaneously over several days. In these situations, it is even same day RTP supported by NFL studies without a risk ofexpected that an athlete will proceed progressively through recurrence or sequelae.61 There is data, however, demonstrat-a stepwise return to play strategy.57 During this period of ing that, at the collegiate and high school level, athletesTABLE 1. Graduated Return to Play Protocol Rehabilitation Stage Functional Exercise at Each Stage of Rehabilitation Objective of Each Stage1. No activity Complete physical and cognitive rest Recovery2. Light aerobic exercise Walking, swimming or stationary cycling keeping Increase HR intensity ,70% MPHR; no resistance training3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; Add movement no head impact activities4. Non-contact training drills Progression to more complex training drills, eg, Exercise, coordination, and cognitive load passing drills in football and ice hockey; may start progressive resistance training5. Full contact practice Following medical clearance, participate in normal Restore confidence and assess functional skills training activities by coaching staff6. Return to play Normal game play188 | q 2009 Lippincott Williams Wilkins
  5. 5. Clin J Sport Med Volume 19, Number 3, May 2009 Consensus Statement on Concussionallowed to RTP on the same day may demonstrate NP deficits protective equipment employed at time of injury be sought,post-injury that may not be evident on the sidelines and are both for recent and remote injuries. The benefit a comprehen-more likely to have delayed onset of symptoms.62–68 It should sive pre-participation concussion evaluation allows forbe emphasized, however, that the young (,18) elite athlete modification and optimization of protective behavior and isshould be treated more conservatively even though the an opportunity for education.resources may be the same as an older professional athlete.(See section 6.1.) 5. MODIFYING FACTORS IN4.3 Psychological Management and Mental CONCUSSION MANAGEMENTHealth Issues The consensus panel agreed that a range of ÔmodifyingÕ In addition, psychological approaches may have factors may influence the investigation and management ofpotential application in this injury, particularly with the concussion and in some cases may predict the potential formodifiers listed below.69,70 Care givers are also encouraged to prolonged or persistent symptoms. These modifiers would alsoevaluate the concussed athlete for affective symptoms such as be important to consider in a detailed concussion history anddepression, as these symptoms may be common in concussed are outlined in Table 2.athletes.57 In this setting, there may be additional management considerations beyond simple RTP advice. There may be4.4 The Role of Pharmacological Therapy a more important role for additional investigations including Pharmacological therapy in sports concussion may be formal NP testing, balance assessment, and neuroimaging. It isapplied in two distinct situations. The first of these situations is envisioned that athletes with such modifying features wouldthe management of specific prolonged symptoms (eg, sleep be managed in a multidisciplinary manner coordinated bydisturbance, anxiety, etc.). The second situation is where drug a physician with specific expertise in the management oftherapy is used to modify the underlying pathophysiology concussive injury.of the condition with the aim of shortening the duration of The role of female gender as a possible modifier in thethe concussion symptoms.71 In broad terms, this approach to management of concussion was discussed at length by themanagement should be only considered by clinicians expe- panel. There was not unanimous agreement that the currentrienced in concussion management. published research evidence is conclusive that this should be An important consideration in RTP is that concussed included as a modifying factor, although it was accepted thatathletes should not only be symptom free but also should gender may be a risk factor for injury and/or influence injurynot be taking any pharmacological agents/medications that severity.76–78may mask or modify the symptoms of concussion. Whereantidepressant therapy may be commenced during the 5.1 The Significance of Loss ofmanagement of a concussion, the decision to return to play Consciousness (LOC)while still on such medication must be considered carefully In the overall management of moderate to severeby the treating clinician. traumatic brain injury, duration of LOC is an acknowledged4.5 The Role of Pre-participationConcussion Evaluation TABLE 2. Concussion Modifiers Recognizing the importance of a concussion history, and Factors Modifierappreciating the fact that many athletes will not recognize all Symptoms Numberthe concussions they may have suffered in the past, a detailed Duration (.10 days)concussion history is of value.72–75 Such a history may pre- Severityidentify athletes that fit into a high risk category and provides Signs Prolonged LOC (.1 min), amnesiaan opportunity for the healthcare provider to educate the Sequelae Concussive convulsionsathlete in regard to the significance of concussive injury. A Temporal Frequency - repeated concussions over timestructured concussion history should include specific ques- Timing - injuries close together in timetions as to previous symptoms of a concussion, not just the ‘‘Recency’’ - recent concussion or TBIperceived number of past concussions. It is also worth noting Threshold Repeated concussions occurring withthat dependence upon the recall of concussive injuries by progressively less impact force or slowerteammates or coaches has been demonstrated to be unreli- recovery after each successive concussionable.72 The clinical history should also include information Age Child and adolescent (,18 years old)about all previous head, face or cervical spine injuries, as these Co- and Pre-morbidities Migraine, depression or other mental healthmay also have clinical relevance. It is worth emphasizing that, disorders, attention deficit hyperactivityin the setting of maxillofacial and cervical spine injuries, co- disorder (ADHD), learning disabilities (LD), sleep disordersexistent concussive injuries may be missed unless specifically Medication Psychoactive drugs, anticoagulantsassessed. Questions pertaining to disproportionate impact Behaviour Dangerous style of playversus symptom severity matching may alert the clinician to Sport High-risk activity, contact and collision sport,a progressively increasing vulnerability to injury. As part high sporting levelof the clinical history it is advised that details regardingq 2009 Lippincott Williams Wilkins | 189
  6. 6. McCrory et al Clin J Sport Med Volume 19, Number 3, May 2009predictor of outcome.79 Whilst published findings in concus- ADHD who may need more sophisticated assessmentsion describe LOC associated with specific early cognitive strategies.31,32,101deficits, it has not been noted as a measure of injury The panel strongly endorsed the view that childrenseverity.80,81 Consensus discussion determined that prolonged should not be returned to practice or play until clinically(.1 minute duration) LOC would be considered as a factor completely symptom free, which may require a longer timethat may modify management. frame than for adults. In addition, the concept of Ôcognitive restÕ was highlighted with special reference to a child’s need5.2 The Significance of Amnesia and to limit exertion with activities of daily living and to limitOther Symptoms scholastic and other cognitive stressors (eg, text messaging, There is renewed interest in the role of post-traumatic videogames, etc.) while symptomatic. School attendance andamnesia and its role as a surrogate measure of injury activities may also need to be modified to avoid provocationseverity.67,82,83 Published evidence suggests that the nature, of symptoms.burden and duration of the clinical post-concussive symptoms Because of the different physiological responses andmay be more important than the presence or duration of longer recovery after concussion and specific risks (eg, diffuseamnesia alone.80,84,85 Further, it must be noted that retrograde cerebral swelling) related to head impact during childhood andamnesia varies with the time of measurement post-injury and adolescence, a more conservative return to play approach ishence is poorly reflective of injury severity.86,87 recommended. It is appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion5.3 Motor and Convulsive Phenomena in children and adolescents. It is not appropriate for a child or A variety of immediate motor phenomena (eg, tonic adolescent athlete with concussion to RTP on the same day asposturing) or convulsive movements may accompany a con- the injury regardless of the level of athletic performance.cussion. Although dramatic, these clinical features are Concussion modifiers apply even more to this population thangenerally benign and require no specific management beyond adults and may mandate more cautious RTP advice.the standard treatment of the underlying concussive injury.88,89 6.2 Elite vs. Non-Elite Athletes5.4 Depression The panel unanimously agreed that all athletes, regard- Mental health issues (such as depression) have been less of level of participation, should be managed using thereported as a long-term consequence of traumatic brain injury same treatment and return to play paradigm. A more usefulincluding sports related concussion. Neuroimaging studies using construct was agreed whereby the available resources andfMRI suggest that a depressed mood following concussion may expertise in concussion evaluation were of more importance inreflect an underlying pathophysiological abnormality consistent determining management than a separation between elite andwith a limbic-frontal model of depression.52,90–100 non-elite athlete management. Although formal baseline NP screening may be beyond the resources of many sports or individuals, it is recommended that in all organized high-risk 6. SPECIAL POPULATIONS sports consideration be given to having this cognitive6.1 The Child and Adolescent Athlete evaluation regardless of the age or level of performance. There was unanimous agreement by the panel that the 6.3 Chronic Traumatic Brain Injuryevaluation and management recommendations containedherein could be applied to children and adolescents down to Epidemiological studies have suggested an associationthe age of 10 years. Below that age children report concussion between repeated sports concussions during a career and latesymptoms different from adults and would require age- life cognitive impairment. Similarly, case reports have notedappropriate symptom checklists as a component of assess- anecdotal cases where neuro-pathological evidence of chronicment. An additional consideration in assessing the child or traumatic encephalopathy was observed in retired footballadolescent athlete with a concussion is that in the clinical players.108–112 Panel discussion was held, and no consensusevaluation by the healthcare professional there may be the was reached on the significance of such observations at thisneed to include both patient and parent input, as well as teacher stage. Clinicians need to be mindful of the potential for long-and school input when appropriate.101–107 term problems in the management of all athletes. The decision to use NP testing is broadly the same as theadult assessment paradigm. However, timing of testing may 7. INJURY PREVENTIONdiffer in order to assist planning in school and homemanagement (and may be performed while the patient is still 7.1 Protective Equipment – Mouthguardssymptomatic). If cognitive testing is performed then it must be and Helmetsdevelopmentally sensitive until late teen years due to the There is no good clinical evidence that currentlyongoing cognitive maturation that occurs during this period available protective equipment will prevent concussion,which, in turn, makes the utility of comparison to either the although mouthguards have a definite role in preventingperson’s own baseline performance or to population norms dental and oro-facial injury. Biomechanical studies havelimited.20 In this age group it is more important to consider shown a reduction in impact forces to the brain with the use ofthe use of trained neuropsychologists to interpret assessment head gear and helmets, but these findings have not beendata, particularly in children with learning disorders and/or translated to show a reduction in concussion incidence. For190 | q 2009 Lippincott Williams Wilkins
  7. 7. Clin J Sport Med Volume 19, Number 3, May 2009 Consensus Statement on Concussionskiing and snowboarding, there are a number of studies to managers play an important part in ensuring these values aresuggest that helmets provide protection against head and facial implemented on the field of play.57,136–148injury and hence should be recommended for participants inalpine sports.113–116 In specific sports such as cycling, motor 9. FUTURE DIRECTIONSand equestrian sports, protective helmets may prevent other The consensus panelists recognize that research isforms of head injury (eg, skull fracture) that are related to needed across a range of areas in order to answer some criticalfalling on hard road surfaces, and these may be an important research questions. The key areas for research identifiedinjury prevention issue for those sports.116–128 include: Validation of the SCAT27.2 Rule Change Gender effects on injury risk, severity and outcome Consideration of rule changes to reduce head injury Paediatric injury and management paradigmsincidence or severity may be appropriate where a clear-cut Virtual reality tools in the assessment of injurymechanism is implicated in a particular sport. An example of Rehabilitation strategies (eg, exercise therapy)this is in football (soccer) where research studies demonstrated Novel imaging modalities and their role in clinicalthat upper limb to head contact in heading contests accounted assessmentfor approximately 50% of concussions.129 As noted earlier, rule Concussion surveillance using consistent definitions andchanges also may be needed in some sports to allow an effective outcome measuresoff-field medical assessment to occur without compromising the Clinical assessment where no baseline assessment has beenathlete’s welfare, affecting the flow of the game or unduly performedpenalizing the player’s team. It is important to note that rule ÔBest-practiceÕ neuropsychological testingenforcement may be a critical aspect of modifying injury risk in Long-term outcomesthese settings, and referees play an important role in this regard. On-field injury severity predictors7.3 Risk Compensation An important consideration in the use of protective 10. MEDICAL LEGAL CONSIDERATIONSequipment is the concept of risk compensation.130 This is This consensus document reflects the current state ofwhere the use of protective equipment results in behavioral knowledge and will need to be modified according to thechange such as the adoption of more dangerous playing development of new knowledge. It provides an overview oftechniques, which can result in a paradoxical increase in injury issues that may be of importance to healthcare providersrates. This may be a particular concern in child and adolescent involved in the management of sports related concussion. It isathletes where head injury rates are often higher than in adult not intended as a standard of care and should not be interpretedathletes.131–133 as such. This document is only a guide and is of a general nature consistent with the reasonable practice of a healthcare7.4 Aggression vs. Violence in Sport professional. Individual treatment will depend on the facts and The competitive/aggressive nature of sport which makes circumstances specific to each individual fun to play and watch should not be discouraged. However, It is intended that this document will be formallysporting organizations should be encouraged to address reviewed and updated prior to 1 December 2012.violence that may increase concussion risk.134,135 Fair play 11. STATEMENT ON BACKGROUND TOand respect should be supported as key elements of sport. CONSENSUS PROCESS In November 2001, the 1st International Conference on 8. KNOWLEDGE TRANSFER Concussion in Sport was held in Vienna, Austria. This meeting As the ability to treat or reduce the effects of concussive was organized by the IIHF in partnership with FIFA and theinjury after the event is minimal, education of athletes, Medical Commission of the IOC. As part of the resulting mandatecolleagues and the general public is a mainstay of progress in for the future, the need for leadership and future updates werethis field. Athletes, referees, administrators, parents, coaches identified. The 2nd International Conference on Concussion inand health care providers must be educated regarding the Sport was organized by the same group with the additionaldetection of concussion, its clinical features, assessment involvement of the IRB and was held in Prague, Czech Republic,techniques and principles of safe return to play. Methods to in November 2004. The original aims of the symposia were toimprove education including web-based resources, educational provide recommendations for the improvement of safety andvideos and international outreach programs are important in health of athletes who suffer concussive injuries in ice hockey,delivering the message. In addition, concussion working rugby, football (soccer) as well as other sports. To this end, a rangegroups, plus the support and endorsement of enlightened sport of experts were invited to both meetings to address specific issuesgroups such as Federation Internationale de Football Associ- ´ ´ of epidemiology, basic and clinical science, injury gradingation (FIFA), International Olympic Commission (IOC), systems, cognitive assessment, new research methods, protectiveInternational Rugby Board (IRB) and International Ice Hockey equipment, management, prevention and long-term outcome.1,2Federation (IIHF) who initiated this endeavor, have enormous The 3rd International Conference on Concussion in Sportvalue and must be pursued vigorously. Fair play and respect for was held in Zurich, Switzerland, on 29/30 October 2008 andopponents are ethical values that should be encouraged in all was designed as a formal consensus meeting followingsports and sporting associations. Similarly, coaches, parents and the organizational guidelines set forth by the US Nationalq 2009 Lippincott Williams Wilkins | 191
  8. 8. McCrory et al Clin J Sport Med Volume 19, Number 3, May 2009Institutes of Health. (Details of the consensus methodology 8. McCrea M, Kelly JP, Kluge J, et al. Standardized assessment ofcan be obtained at concussion in football players. Neurology. 1997;48:586–588. 9. Chen J, Johnston K, Collie A, et al. A validation of the post concussionhtm.) The basic principles governing the conduct of a con- symptom scale in the assessment of complex concussion using cognitivesensus development conference are summarized below: testing and functional MRI. J Neurol Neurosurg Psych. 2007;78:1231–1. A broad based non-government, non-advocacy panel was 1238. assembled to give balanced, objective and knowledgeable 10. Chen J, Johnston K, Frey S, et al. Functional abnormalities in symptomatic concussed athletes: an fMRI study. Neuroimage. 2004;22:68–82. attention to the topic. Panel members excluded anyone with 11. Chen JK, Johnston KM, Collie A, et al. Association between symptom scientific or commercial conflicts of interest and included severity, cogsport tests results, and functional MRI activation in researchers in clinical medicine, sports medicine, neuro- symptomatic concussed athletes. Clin J Sport Med. 2004;14:379. science, neuroimaging, athletic training and sports science. 12. Chen JK, Johnston KM, Collie A, et al. Behavioural and functional2. These experts presented data in a public session, followed imaging outcomes in symptomatic concussed athletes measured with cogsport and functional MRI. Br J Sports Med. 2004;38:659. by inquiry and discussion. The panel then met in an 13. Ptito A, Chen JK, Johnston KM. Contributions of functional magnetic executive session to prepare the consensus statement. resonance imaging (fMRI) to sport concussion evaluation. Neuro-3. A number of specific questions were prepared and posed in Rehabilitation. 2007;22:217–227. advance to define the scope and guide the direction of the 14. Guskiewicz K. Postural stability assessment following concussion. Clin conference. The principle task of the panel was to elucidate J Sport Med. 2001;11:182–190. 15. Guskiewicz KM. Assessment of postural stability following sport-related responses to these questions. These questions are outlined concussion. Current Sports Medicine Reports. 2003;2:24–30. above. 16. Guskiewicz KM, Ross SE, Marshall SW. Postural stability and4. A systematic literature review was prepared and circulated neuropsychological deficits after concussion in collegiate athletes. in advance for use by the panel in addressing the conference J Athl Train. 2001;36:263-273. questions. 17. Cavanaugh JT, Guskiewicz KM, Giuliani C, et al. Detecting altered postural control after cerebral concussion in athletes with normal5. The consensus statement is intended to serve as the postural stability. Br Journal Sports Med. 2005;39:805–811. scientific record of the conference. 18. Cavanaugh JT, Guskiewicz KM, Giuliani C, et al. Recovery of postural6. The consensus statement will be widely disseminated to control after cerebral concussion: new insights using approximate achieve maximum impact on both current health care entropy. J Athl Train. 2006;41:305–313. practice and future medical research. 19. Cavanaugh JT, Guskiewicz KM, Stergiou N. A nonlinear dynamic approach for evaluating postural control: new directions for the The panel chairperson (WM) did not identify with any management of sport-related cerebral concussion. Sports Medicine.advocacy position. The chairperson was responsible for 2005;35:935–950.directing the consensus session and guiding the panel’s 20. Fox ZG, Mihalik JP, Blackburn JT, et al. Return of postural control todeliberations. Panelists were drawn from clinical practice, baseline after anaerobic and aerobic exercise protocols. J Athl Train.academic and research in the field of sports related concussion. 2008;43:456–463. 21. Collie A, Darby D, Maruff P. 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  15. 15. Sport Concussion Assessment Tool 2 (SCAT2)
  16. 16. Pocket SCAT2