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This summary statement regarding the potential for long-term sequelae following recurrent head trauma must be read in conjunction with the systematic review paper, which details the background, search strategy, citations and reasoning for this statement.25
The literature on neurobehavioral sequelae and long-term consequences of exposure to recurrent head trauma is inconsistent. Clinicians need to be mindful of the potential for long-term problems such as cognitive impairment, depression, etc in the management of all athletes. However, there is much more to learn about the potential cause-and-effect relationships of repetitive head-impact exposure and concussions. The potential for developing chronic traumatic encephalopathy (CTE) must be a consideration, as this condition appears to represent a distinct tauopathy with an unknown incidence in athletic populations. A cause-and-effect relationship has not yet been demonstrated between CTE and SRCs or exposure to contact sports. As such, the notion that repeated concussion or subconcussive impacts cause CTE remains unknown.
The new US National Institutes of Neurological Disease and Stroke (NINDS) and National Institute of Biomedical Imaging and Bioengineering (NIBIB) consensus criteria provide a standardised approach for describing the neuropathology of CTE. More research on CTE is needed to better understand the incidence and prevalence, the extent to which the NP findings cause specific clinical symptoms, the extent to which the neuropathology is progressive, the clinical diagnostic criteria, and other risk or protective factors. Ideally, well-designed case–control or cohort studies can begin to answer these important questions.
that many athletes will not recognise all the SRCs they may have suffered in the past, a detailed SRC history is of value.26–29 Such a history may identify athletes who fit into a high-risk category and provides an opportunity for the healthcare provider to educate the athlete as to the significance of concussive injury.
A structured SRC history should include specific questions as to previous symptoms of an SRC and length of recovery, not just the perceived number of past SRCs. Note that dependence on the recall of concussive injuries by teammates or coaches is unreliable.26 The clinical history should also include information about all previous head, face or cervical spine injuries, as these may also have clinical relevance. In the setting of maxillofacial and cervical spine injuries, coexistent concussive injuries may be missed unless specifically assessed. Questions pertaining to disproportionate impact versus symptom-severity matching may alert the clinician to a progressively increasing vulnerability to injury. As part of the clinical history, the health practitioner should seek details regarding protective equipment used at the time of injury for both recent and remote injuries.
There is an additional and often unrecognized benefit of the pre-participation physical examination insofar as the evaluation provides an educative opportunity with the player concerned, as well as consideration of modification of playing behavior if required.
While it is impossible to eliminate all concussion in sport, concussion-prevention strategies can reduce the number and severity of concussions in many sports. Until the past decade, there has been a relative paucity of scientifically rigorous evaluation studies examining the effectiveness of concussion-prevention strategies in sport.
The evidence examining the protective effect of helmets in reducing the risk of SRC is limited in many sports because of the nature of mandatory helmet regulations. There is sufficient evidence in terms of reduction of overall head injury in skiing/snowboarding to support strong recommendations and policy to mandate helmet use in skiing/snowboarding. The evidence for mouthguard use in preventing SRC is mixed, but meta-analysis suggests a non-significant trend towards a protective effect in collision sports, and rigorous case–control designs are required to further evaluate this finding.
The strongest and most consistent evidence evaluating policy is related to body checking in youth ice hockey (ie, disallowing body checking under age 13), which demonstrates a consistent protective effect in reducing the risk of SRC. This evidence has informed policy change in older age groups in non-elite levels, which requires further investigation.
There is minimal evidence to support individual injury-prevention strategies addressing intrinsic risk factors for SRC in sport. However, there is some promise that vision training in collegiate American football players may reduce SRC. Limiting contact in youth football practices has demonstrated some promising results in reducing the frequency of head contact, but there is no evidence to support the translation of these findings to a reduction in SRC. Evaluation of fair play rules in youth ice hockey, tackle training without helmets and shoulder pads in youth American football, and tackle technique training in professional rugby do not lead to a reduction in SRC risk. A recommendation for stricter rule enforcement of red cards for high elbows in heading duels in professional soccer is based on evidence supporting a reduced risk of head contacts and concussion with such enforcement.
Despite a myriad of studies examining SRC-prevention interventions across several sports, some findings remain inconclusive because of conflicting evidence, lack of rigorous study design, and inherent study biases. A clear understanding of potentially modifiable risk factors is required to design, implement and evaluate appropriate prevention interventions to reduce the risk of SRC. In addition, risk factors should be considered as potential confounders or effect modifiers in any evaluation. Biomechanical research (eg, video-analysis) to better understand injury risk behaviour and mechanisms of injury associated with rules will better inform practice and policy decisions. In addition, psychological and sociocultural factors in sport play a significant role in the uptake of any injury-prevention strategy and require consideration.
The value of knowledge translation (KT) as part of SRC education is increasingly becoming recognised. Target audiences benefit from specific learning strategies. SRC tools exist, but their effectiveness and impact require further evaluation. The media is valuable in drawing attention to SRC, but efforts need to ensure that the public is aware of the right information, including uncertainties about long-term risks of adverse outcomes. Social media is becoming more prominent as an SRC education tool. Implementation of KT models is one approach organizations can use to assess knowledge gaps, identify, develop and evaluate education strategies, and use the outcomes to facilitate decision-making. Implementing KT strategies requires a defined plan. Identifying the needs, learning styles and preferred learning strategies of target audiences, coupled with evaluation, should be a piece of the overall SRC education puzzle to have an impact on enhancing knowledge and awareness.
As the ability to treat or reduce the effects of concussive injury after the event is an evolving science, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and healthcare providers must be educated regarding the detection of SRC, its clinical features, assessment techniques and principles of safe return to play. Methods to improve education, including web-based resources, educational videos and international outreach programs, are important in delivering the message. Fair play and respect for opponents are ethical values that should be encouraged in all sports and sporting associations. Similarly, coaches, parents and managers play an important part in ensuring these values are implemented on the field of play.30–43
In addition, the support and endorsement of sporting bodies such as the International Ice Hockey Federation, Federation International de Football Association (FIFA) and the International Olympic Committee who initiated this endeavour, as well as organizations that have subsequently supported the CISG meetings, including World Rugby, the International Equestrian Federation and the International Paralympic Committee, should be commended.
Since the 1970s, clinicians and scientists have begun to distinguish SRC from other causes of concussion and mTBI, such as motor vehicle crashes. While this seems like an arbitrary separation from other forms of TBI, which account for 80% of such injuries,44 45 it is largely driven by sporting bodies that see the need to have clear and practical guidelines to determine recovery and safe return to play for athletes with an SRC.
In addition, sports participation provides unique opportunities to study SRC and mTBI, given the detailed SRC phenotype data that are typically available in many sports.46 Having said that, it is critical to understand that the lessons derived from non-sporting mTBI research informs the understanding of SRC (and vice versa), and this arbitrary separation of sporting versus non-sporting TBI should not be viewed as a dichotomous or exclusive view of TBI. One of the standout features of the Berlin CISG meeting was the engagement by experts from the TBI, dementia, imaging and biomarker world in the process and as coauthors of the systematic reviews, which are published in issue 10 of the British Journal of Sports Medicine (Volume 51, 2017).
This consensus document reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It should be read in conjunction with the systematic reviews and methodology papers that accompany this document (British Journal of Sports Medicine, issues 11 and 12, 2017). This document is first and foremost intended to inform clinical practice; however, it must be remembered that, while agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of concussion is incomplete and therefore management and return-to-play decisions lie largely in the realm of clinical judgement on an individualized basis.
Graduated return-to-sport (RTS) strategy
After a brief period of initial rest (24–48 hours), symptom-limited activity can be begun while staying below a cognitive and physical exacerbation threshold (stage 1). Once concussion-related symptoms have resolved, the athlete should continue to proceed to the next level if he/she meets all the criteria (eg, activity, heart rate, duration of exercise, etc) without a recurrence of concussion-related symptoms. Generally, each step should take 24 hours, so that athletes would take a minimum of 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest. However, the time frame for RTS may vary with player age, history, level of sport, etc, and management must be individualised.
In athletes who experience prolonged symptoms and resultant inactivity, each step may take longer than 24 hours simply because of limitations in physical conditioning and recovery strategies outlined above. This specific issue of the role of symptom-limited exercise prescription in the setting of prolonged recovery is discussed in an accompanying systematic review.24 If any concussion-related symptoms occur during the stepwise approach, the athlete should drop back to the previous asymptomatic level and attempt to progress again after being free of concussion-related symptoms for a further 24 hour period at the lower level.
The CISG also considered whether special populations should be managed differently and made recommendations for elite and young athletes
All athletes, regardless of level of participation, should be managed using the same management principles noted above.
the developing child. The paucity of studies that are specific to children, especially younger children, needs to be addressed as a priority, with the expectation that future CISG consensus meetings will have sufficient studies to review that are age-specific, of high quality, and with a low risk of bias.
We recommend that child and adolescent guidelines refer to individuals 18 years or less. Child-specific paradigms for SRC should apply to children aged 5–12 years, and adolescent-specific paradigms should apply to those aged 13–18 years. The literature does not adequately address the question of age groups in which children with SRC should be managed differently from adults. No studies have addressed whether SRC signs and symptoms differ from adults. The expected duration of symptoms in children with SRC is up to 4 weeks, and further research is required to identify predictors of prolonged recovery. It is recommended that age-specific validated symptom-rating scales be used in SRC assessment, and further research is required to establish the role and utility of computerised NP testing in this age group. Similar to adults, a brief period of physical and cognitive rest is advised after SRC followed by symptom-limited resumption of activity.
Schools are encouraged to have an SRC policy that includes education on SRC prevention and management for teachers, staff, students and parents, and should offer appropriate academic accommodation and support to students recovering from SRC. Students should have regular medical follow-up after an SRC to monitor recovery and help with return to school, and students may require temporary absence from school after injury.
Children and adolescents should not return to sport until they have successfully returned to school. However, early introduction of symptom-limited physical activity is appropriate.
An example of the return-to-school progression is in table 2.
Graduated return-to-sport (RTS) strategy
After a brief period of initial rest (24–48 hours), symptom-limited activity can be begun while staying below a cognitive and physical exacerbation threshold (stage 1). Once concussion-related symptoms have resolved, the athlete should continue to proceed to the next level if he/she meets all the criteria (eg, activity, heart rate, duration of exercise, etc) without a recurrence of concussion-related symptoms. Generally, each step should take 24 hours, so that athletes would take a minimum of 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest. However, the time frame for RTS may vary with player age, history, level of sport, etc, and management must be individualised.
In athletes who experience prolonged symptoms and resultant inactivity, each step may take longer than 24 hours simply because of limitations in physical conditioning and recovery strategies outlined above. This specific issue of the role of symptom-limited exercise prescription in the setting of prolonged recovery is discussed in an accompanying systematic review.24 If any concussion-related symptoms occur during the stepwise approach, the athlete should drop back to the previous asymptomatic level and attempt to progress again after being free of concussion-related symptoms for a further 24 hour period at the lower level.
Reconsider
The CISG also considered whether special populations should be managed differently and made recommendations for elite and young athletes.
Elite and non-elite athletes
All athletes, regardless of level of participation, should be managed using the same management principles noted above.
The child and adolescent athlete
The management of SRC in children requires special paradigms suitable for the developing child. The paucity of studies that are specific to children, especially younger children, needs to be addressed as a priority, with the expectation that future CISG consensus meetings will have sufficient studies to review that are age-specific, of high quality, and with a low risk of bias.
We recommend that child and adolescent guidelines refer to individuals 18 years or less. Child-specific paradigms for SRC should apply to children aged 5–12 years, and adolescent-specific paradigms should apply to those aged 13–18 years. The literature does not adequately address the question of age groups in which children with SRC should be managed differently from adults. No studies have addressed whether SRC signs and symptoms differ from adults. The expected duration of symptoms in children with SRC is up to 4 weeks, and further research is required to identify predictors of prolonged recovery. It is recommended that age-specific validated symptom-rating scales be used in SRC assessment, and further research is required to establish the role and utility of computerised NP testing in this age group. Similar to adults, a brief period of physical and cognitive rest is advised after SRC followed by symptom-limited resumption of activity.
Schools are encouraged to have an SRC policy that includes education on SRC prevention and management for teachers, staff, students and parents, and should offer appropriate academic accommodation and support to students recovering from SRC. Students should have regular medical follow-up after an SRC to monitor recovery and help with return to school, and students may require temporary absence from school after injury.
Children and adolescents should not return to sport until they have successfully returned to school. However, early introduction of symptom-limited physical activity is appropriate.
An example of the return-to-school progression is in table 2.