- Aubry M.
- Cantu R.
- Dvorak J.
- Graf-Baumann T.
- Johnston K.
- Kelly J.
- et al.
- Acute simple concussion
- •Which symptom scale and which sideline assessment tool is best for diagnosis and/or follow up?
- •How extensive should the cognitive assessment be in elite athletes?
- •How extensive should clinical and neuropsychological (NP) testing be at non-elite level?
- •Who should do/interpret the cognitive assessment?
- •Is there a gender difference in concussion incidence and outcomes?
- 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?
- •Is protective equipment (e.g. mouthguards and helmets) useful in reducing concussion incidence and/or severity?
- Complex concussion and long-term issues
- •Is the simple versus complex classification a valid and useful differentiation?
- •Are there specific patient populations at risk of long-term problems?
- •Is there a role for additional tests (e.g. structural and/or functional MR Imaging, balance testing, biomarkers)?
- •Should athletes with persistent symptoms be screened for depression/anxiety?
- Paediatric concussion
- •Which symptoms scale is appropriate for this age group?
- •Which tests are useful and how often should baseline testing be performed in this age group?
- •What is the most appropriate RTP guideline for elite and non-elite child and adolescent athlete?
- Future directions
- •What is the best method of knowledge transfer and education?
- •Is there evidence that new and novel injury prevention strategies work (e.g. changes to rules of the game, fair play strategies, etc.)?
1.1 Definition of concussion
Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:
- 1.Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head.
- 2.Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
- 3.Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
- 4.Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course however it is important to note that in a small percentage of cases however, post-concussive symptoms may be prolonged.
- 5.No abnormality on standard structural neuroimaging studies is seen in concussion.
1.2 Classification of concussion
2. Concussion evaluation
2.1 Symptoms and signs of acute concussion
- (a)Symptoms—somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g. lability)
- (b)Physical signs (e.g. loss of consciousness, amnesia)
- (c)Behavioural changes (e.g. irritability)
- (d)Cognitive impairment (e.g. slowed reaction times)
- (e)Sleep disturbance (e.g. drowsiness)
2.2 On-field or sideline evaluation of acute concussion
- (a)The player should be medically evaluated onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury.
- (b)The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.
- (c)Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT2 or other similar tool.
- (d)The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury.
- (e)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 return to play on the same day as the injury (See Section 4.2).
2.3 Evaluation in emergency room or office by medical personnel
- (a)A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance.
- (b)A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury.
- (c)A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality.
3. Concussion investigations
3.2 Objective balance assessment
3.3 Neuropsychological Assessment
3.4 Genetic testing
3.5 Experimental concussion assessment modalities
4. Concussion management
4.1 Graduated return to play protocol
|Rehabilitation stage||Functional exercise at each stage of rehabilitation||Objective of each stage|
|1. No activity||Complete physical and cognitive rest||Recovery|
|2. Light aerobic exercise||Walking, swimming or stationary cycling keeping intensity <70% MPHR||Increase HR|
|No resistance training.|
|3. Sport-specific exercise||Skating drills in ice hockey, running drills in soccer. No head impact activities||Add movement|
|4. Non-contact training drills||Progression to more complex training drills, e.g. passing drills in football and ice hockey||Exercise, coordination, and cognitive load|
|May start progressive resistance training)|
|5. Full contact practice||Following medical clearance participate in normal training activities||Restore confidence and assess functional skills by coaching staff|
|6. Return to play||Normal game play|
4.2 Same day RTP
4.3 Psychological management and mental health issues
4.4 The role of pharmacological therapy
4.5 The role of pre-participation concussion evaluation
5. Modifying factors in concussion management
|Duration (>10 days)|
|Signs||Prolonged LOC (>1 min), Amnesia|
|Temporal||Frequency—repeated concussions over time|
|Timing—injuries close together in time|
|“Recency”—recent concussion or TBI|
|Threshold||Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion.|
|Age||Child and adolescent (<18 years old)|
|Co and pre-morbidities||Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders|
|Medication||Psychoactive drugs, anticoagulants|
|Behaviour||Dangerous style of play|
|Sport||High risk activity, contact and collision sport, high sporting level|
5.1 The significance of loss of consciousness (LOC)
5.2 The significance of amnesia and other symptoms
5.3 Motor and convulsive phenomena
6. Special populations
6.1 The child and adolescent athlete
6.2 Elite vs non-elite athletes
6.3 Chronic traumatic brain injury
7. Injury prevention
7.1 Protective equipment – mouthguards and helmets
7.2 Rule change
7.3 Risk compensation
7.4 Aggression versus violence in sport
8. Knowledge transfer
9. Future directions
- •Validation of the SCAT2
- •Gender effects on injury risk, severity and outcome
- •Paediatric injury and management paradigms
- •Virtual reality tools in the assessment of injury
- •Rehabilitation strategies (e.g. exercise therapy)
- •Novel imaging modalities and their role in clinical assessment
- •Concussion surveillance using consistent definitions and outcome measures
- •Clinical assessment where no baseline assessment has been performed
- •‘Best-practice’ neuropsychological testing
- •Long-term outcomes
- •On-field injury severity predictors
10. Medical legal considerations
11. Statement on background to consensus process
- Aubry M.
- Cantu R.
- Dvorak J.
- Graf-Baumann T.
- Johnston K.
- Kelly J.
- et al.
- 1.A broad-based non-government, non-advocacy panel was assembled to give balanced, objective and knowledgeable attention to the topic. Panel members excluded anyone with scientific or commercial conflicts of interest and included researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sports science.
- 2.These experts presented data in a public session, followed by inquiry and discussion. The panel then met in an executive session to prepare the consensus statement.
- 3.A number of specific questions were prepared and posed in advance to define the scope and guide the direction of the conference. The principle task of the panel was to elucidate responses to these questions. These questions are outlined below.
- 4.A systematic literature review was prepared and circulated in advance for use by the panel in addressing the conference questions.
- 5.The consensus statement is intended to serve as the scientific record of the conference.
- 6.The consensus statement will be widely disseminated to achieve maximum impact on both current health care practice and future medical research.
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☆Consensus panelists (listed in alphabetical order): In addition to the authors above, the consensus panellists were S. Broglio, G. Davis, R. Dick, J. Dvorak, R. Echemendia, G. Gioia, K. Guskiewicz, S. Herring, G. Iverson, J. Kelly, J. Kissick, M. Makdissi, M. McCrea, A. Ptito, L. Purcell, M. Putukian. Also invited but not in attendance: R. Bahr, L. Engebretsen, P. Hamlyn, B. Jordan, P. Schamasch.