For the concussion world, the release of the international consensus statement on concussion in sport is an important milestone. We have made significant progress in the past four years since the release of the last statement, and we applaud the Concussion In Sport Group (CISG) for consistently providing expert-based approaches and recommendations for sport-related concussion (SRC).
We will examine the highlights and major changes to the 5th version of the Consensus Statement on Concussion in Sport. The highlights include more support for early activation, exercise, and physical and manual therapies for the treatment of concussion symptoms, a trend towards support for baseline testing and pre-participation evaluations, as well as improved SCAT tools; SCAT5 and Child SCAT5.
The consensus statement discusses “the 11 R’s” of SRC management: Recognize; Remove; Re-evaluate; Rest; Rehabilitation; Refer; Recovery; Return to sport; Reconsider; Residual effects and sequelae; and Risk reduction.
Recognize: Defining concussion, helmet sensors, and the sideline evaluation
A major update to the definition of concussion includes: “The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (cervical spine, peripheral vestibular dysfunction, etc.) or other comorbidities (psychological factors of coexisting medical conditions).” This addition acknowledges the fact that the symptoms of concussion are not specific and can overlap with a number of other possible conditions. While it may be easier to rule out intoxication, ruling out other injuries such as neck and vestibular issues may be a bit more challenging in the acute stages.
The expert committee also noted that the use of helmet-based or other sensor systems to clinically diagnose or assess concussion cannot be supported. We believe that further research trials are required before sensors are utilized to diagnose SRC, and their initial use should support recommended practices to identify those who should undergo an assessment for concussion.
Sideline assessment using the SCAT5 tool is supported as a multimodal assessment approach, which is useful on-field; however, offers limited value several days after an injury. Pre-season baseline testing can support healthcare practitioners to interpret the scores of post-injury tests. The CISG also suggests that supplemental domains can add value to the clinical utility of the SCAT5 tool, including reaction time, gait/balance assessment, and oculomotor screening; tests that are currently included in the CCMI baseline testing battery.
Remove and evaluate
“When a concussion is suspected, the athlete should be removed from the sporting environment and a multimodal assessment should be conducted in a standardized fashion (SCAT5).” As per the previous consensus statement, concussions should be evaluated by a physician or other licensed healthcare provider with training and experience in concussion management.
Re-evaluate: procedures in the clinic
There were no notable changes here. The recommendations continue to support an initial examination consisting of a thorough history, cranial nerves, cerebellar, oculomotor, vestibular, mental status, rule out red-flags and the need for emergent neuroimaging.
Neuropsychological assessment: Symptom recovery and beyond
Cognitive recovery can precede or lag behind symptom recovery; therefore assessing cognitive function is an important component of overall assessment. However, it should never be the sole basis for any concussion management decision.
Although not mandatory to all participation, baseline neuropsychological assessments may provide additional information to the overall interpretation of these tests. It also allows for an additional educative opportunity for healthcare providers to discuss the seriousness of concussions with athletes and athletic support staff.
The statement confirms that there is currently not enough evidence for biomarkers (blood, CSF, saliva) or advanced functional imaging in the diagnosis or management of concussions.
Redefining rest: Rest for a day or two, then get active!
“There is currently insufficient evidence that prescribing complete rest achieves these objectives (i.e., ease discomfort, mitigate post-concussion symptoms and/or promote recovery). After a brief period of rest during the acute phase (24 – 48 hours), patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds.”
This is a notable update in comparison to statements from previous years. CCMI supports the CISG and the recommendation to move away from long periods of rest. While this does not mean returning to sport, there could be opportunities for an athlete to increase non-contact activities, which may include stationary bike, walking, or swimming, among others. It’s important that athletes work with their trained concussion management team to determine their level of activity
Rehabilitation and refer: The importance of early access to a trained therapy team
Persistent symptoms (>10 – 14 days in adults and >4 weeks in children) should be managed by an individualized program consisting of multidisciplinary care.
“Concussion can result in diverse symptoms and problems, and can be associated with concurrent injury to the cervical spine (neck) and peripheral vestibular system… The data support interventions including psychological, cervical and vestibular rehabilitation… In addition, closely monitored active rehabilitation programmes involving controlled sub-symptom-threshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery.”
Physicians and healthcare providers involved in concussion management have made significant progress in this area, supported by a wealth of research from around the world since the last consensus statement. We are pleased that these updates have been included in the most recent consensus statement.
There is currently limited evidence to support the use of medications for concussion symptoms.
Recovery: Beware of the post-concussion physiologic vulnerability when making return to sport decisions, and psychological factors hindering symptom recovery
Symptom recovery may happen before true physiological (neurobiological) recovery in the brain occurs. This means “that athletes may be exposed to additional risk by returning to play while there is ongoing brain dysfunction.” Further research is required to fully understand this period of vulnerability; and, the consensus statement suggests that recovery encompasses “a resolution of post-concussion-related symptoms and a return to clinically normal balance and cognitive functioning.”
Completing comprehensive baseline tests prior to the start of a season offers healthcare practitioners valuable and objective information to help make these difficult decisions.
Symptoms are not specific to a concussion and there is a growing body of literature that shows that psychological factors play a significant role in symptom recovery.
In terms of prognosis, the strongest predictor of prolonged symptoms is the severity of symptoms within the first few days after injury. We believe that this statement should be taken with a grain of salt since there is research available to support that those with pre-existing anxiety and/or poor coping skills (which are also known to increase likelihood of chronicity), tend to present with a higher initial symptom score. In our opinion, a higher symptom score should therefore be met with more education and reassurance to mitigate the risk of prolonged symptoms, which may be anxiety driven. Perhaps we wouldn’t see the same effect on recovery.
Return to sport: Remains a six-step process, but when to return-to-school?
The multi-disciplinary CISG continues to support a step-by-step process to return to play with at least 24 hours between each step. If an athlete experiences symptoms at any step then they should return to the previous step.
One notable addition to the statement is a return-to-school strategy. At CCMI, we typically recommend a four-step return-to-school strategy prior to the six-step return-to-sport for a total 10-step process. We find that this allows for a more gradual return-to-play, which, in our opinion, increases the likelihood of an athlete being out of their vulnerable state prior to receiving clearance.
Residual effects and sequelae: Long-term effects of concussions remain unknown
There is still much to learn on the potential association between concussion/recurrent head trauma and long-term effects. There continues to be a need for additional research to fully understand the cause-effect relationship established between concussion and CTE.
Risk reduction: Reducing contact in young athletes
Pre-participation evaluation may identify athletes who fit into a high-risk category and also provides an opportunity for concussion education of athletes.
There is still limited evidence to show that helmets reduce the risk of concussion. The strongest evidence towards concussion prevention is the removal of body-checking in youth ice-hockey (under age 13). This can be credited to compelling research coming out of the University of Calgary. There is some evidence that vision training may also reduce the risk of concussion in football players.
Overall, we feel that the CISG group did an excellent job of capturing the current understanding of concussion and concussion management. The mandate of CCMI is to deliver evidence-based care, and as such, we analyze and disseminate the latest research to our clinical network on a monthly basis so that we are always delivering the most effective care to our patients. This document demonstrates the tremendous advancement over the past four years and sets the tone for the next four by revealing areas we need to improve our understanding. Excellent work to all those involved and we look forward to continued progress in an effort to ensure our athletes receive the best possible concussion care.